Advanced Neuroimaging
Hypermetabolic Neural Activity in People with Post Concussion Syndrome
Revealed by Functional Imaging
Structural Magnetic Resonance Imaging in Concussion
Functional Imaging for Concussion Assessment and Research
A Historical Perspective on Advanced Neuroimaging in Clinics and Courts
Imaging for TBI: Current and Future Prospects
Imaging for Brain Trauma: Questions to Be Answered
BRAIN INJURY PROFESSIONAL

1

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editor in chief’s message
“Now, as humans, we can identify galaxies light years away. We can
study particles smaller than an atom, but we still haven’t unlocked
the mystery of the three pounds of matter that sits between our
ears.”
—President Barack Obama announcing The BRAIN Initiative
(Brain Research through Advancing Innovative
Neurotechnologies) on April 2, 2013.

Ronald Savage, EdD

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BRAIN INJURY PROFESSIONAL

Neuroimaging is the cornerstone to not
only understanding the mysteries of the
human brain, but also what happens to the
brain when it is injured. Today, however, it
is like playing a brain memory game trying
to recall all the neuroimaging technologies
that have been entering our medical-clinical
world over the past two decades. Think
about it: computed axial tomography
(CT), diffuse optical imaging (DOI),
event-related optical signal EOS), magnetic
resonance imaging (MRI), functional
magnetic resonance imaging (fMRI),
magnetoencephalography (MEG), positron
emission tomography (PET), single-photon
emission computed tomography (SPECT),
and still more to come. In this issue of BIP,
Drs. Willer, Leddy and Silver help us to sift
and sort through this maze of neuroimaging
technology and provide us with a sense of
what this all means in brain injury research
and treatment. They have also provided
NABIS Conference participants with a
symposium on neuroimaging to coincide
with this issue.
Although still a relatively young field,
neuroimaging has rapidly advanced
over the years due to breakthroughs
in technology and computational
methods. Applications of neuroimaging
techniques have likewise become farreaching. There is little doubt that in the
future, neuroimaging will be a significant
technology that will help guide our
medical and clinical decision making.
Newer methods, both structural imaging

and functional imaging, are continually
being developed and refined to quantify
damage on images and, hopefully,
improve our predictive power. As such,
imaging has become increasingly vital to
the development of new therapies and
may be used to measure patient response
to various therapies. Imaging has and will
continue to influence therapy and may
improve outcomes for individuals with
brain injuries, whether mild, moderate or
severe.
NABIS extends its appreciation to Drs.
Willer, Leddy and Silver for providing
readers and conference participants with
much needed education in neuroimaging
and its application to brain injury research
and treatment.
Finally, I would like to inform all
members of NABIS that in support of the
International Brain Injury Association’s
Tenth World Congress on Brain Injury,
the Society will not be holding its
regular conferences next year. All NABIS
members are encouraged to attend the
World Congress that will be held March
19-22, 2014, in San Francisco. NABIS
will be back with our regular meetings
April 29 – May 2, 2015, at the beautiful
Westin Riverwalk Hotel in San Antonio,
Texas! Details as they become available
will be posted on the NABIS website,
www.nabis.org.
Ronald Savage, EdD

A brain injury doesn’t have to be a disability.
In each patient we only see capability,
viability,
possibility,
mobility,
sustainability,
ability.

For over 30 years Centre for Neuro Skills (CNS) has been recognized as an experienced
and respected world leader for providing intensive postacute community based brain injury
rehabilitation. With facilities in Texas and California, CNS’ highly trained staff offers
outcome driven medical treatment, therapeutic rehabilitation and disease management
services for individuals recovering from acquired and traumatic brain injury. We’re the
bridge to a meaningful recovery. For additional information about Centre for Neuro Skills,
please visit us at neuroskills.com or call us at 800.554.5448.

BRAIN INJURY PROFESSIONAL

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guest editorsâ&#x20AC;&#x2122; message

Jonathan Silver, MD
Everyone interested in brain injury, either
as a researcher, educator or clinician (and
many families and people living with the
effects of brain injury) share a profound
interest in how the brain works and what
happens when it is not working to capacity.
The more we learn about brain function the
more fascinating and complex it becomes.
Imaging has added considerably to the process of evaluating and studying the brain.
In the past, imaging was critical to providing much needed information about the
structure of the brain and provided some
guidance on specific deficits. Today, imaging has become increasingly powerful and
reveals exquisite details about the structure
and function of the brain, and therefore so
much more about dysfunction.
This issue of Brain Injury Professional
(BIP) is devoted specifically to the topic of
advanced neuroimaging. The authors of
this issue of BIP will be providing much of
this material in a preconference seminar at
the North American Brain Injury Society
(NABIS) conference in September, 2013.
Our primary goal for the seminar and this

6

BRAIN INJURY PROFESSIONAL

Barry Willer, PhD and John Leddy, MD
issue was to provide the reader with basic
information about the methods used in imaging and several research and clinical questions that may be addressed through imaging. You can think of this issue of BIP as a
brief written course on neuroimaging.
The course begins with an introduction
from Barry Willer and John Leddy. They
published a paper on functional magnetic
resonance imaging (fMRI) in the July/August 2013 issue of the Journal of Head Trauma Rehabilitation (JHTR) but took this
occasion to elaborate on findings that were
only touched upon in the scientific publication. They describe the fact that individuals
suffering from mild TBI (mTBI) show hypermetabolic activity to accomplish simple
tasks. This, they say, helps to explain the
fatigue individuals with mTBI so often experience. In our course this provides a practical example of a direct correlation between
imaging and clinical observation.
Paul Polak and David Wack are young
scientists that have specialized in neuroimaging. For our course they have been
charged with the task of describing structur-

al and functional imaging. There are various methods for describing the structures
of the brain and whether these structures
should work or not. Paul Polak provides us
with a wonderful primer on structural imaging that includes the intriguing Diffusion
Tensor Imaging (DTI). David Wack does
the same with functional imaging, describing both MRI approaches as well as Positron Emission Tomography (PET).
The next component of the course examines the usefulness and application of advanced neuroimaging to the clinical setting
and the courtroom. Hal Wortzel provides a
first-rate historical perspective as he walks us
through various examples of the application
of advanced imaging in forensic situations.
He concludes that there is need for healthy
skepticism before we rush to the courtroom
with findings from imaging studies. The
same skepticism can be applied to clinical
applications. Katherine Taber and Robin
Hurley provide an important practical approach as to when and why neuroimaging
might be used to answer clinical questions.
Jonathan Silver provides the exclamation mark at the end of the course. While
researchers have contributed significantly
to our understanding of brain function
through advanced neuroimaging, he urges
caution in rushing to premature conclusions
based on neuroimaging. He points out that
imaging cannot replace careful examination
by an experienced clinician.
We hope that we see you in person at
the NABIS conference and you are able to
attend this preconference seminar. As guest
editors, we want to thank our colleagues
for their generosity and willingness to share
their knowledge and wisdom on imaging, in
the magazine and at the conference.
Barry Willer, PhD
John Leddy, MD
Jonathan Silver, MD

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BRAIN INJURY PROFESSIONAL

7

Hypermetabolic neural activity in people with post
concussion syndrome revealed by functional imaging

by Barry Willer PhD John Leddy MD

Researchers do their best to describe their research in as complete
a fashion as possible each time they publish in scientific journals.
However, these journals, by their nature, place constraints on
telling the ‘whole’ story when it comes to research studies. It
is not that they wish to restrict the researcher; it is simply that
there are page limitations and certain expectations that force
the researcher to focus on the most “significant” results from a
statistical point of view, sometimes excluding the most significant
results for clinicians or patients.
A prime example of this is a recent study we published where
our aim was to evaluate metabolic activity in the brains of individuals with post concussion syndrome (PCS). In this study we
used functional magnetic resonance imaging (fMRI) to describe
the cerebral metabolism associated with a cognitive task performed by subjects with post concussion syndrome (PCS) versus
subjects who were similar in age and athleticism but did not have
PCS (Leddy et al. 2013). We used fMRI to provide a picture of
the metabolic activity in the brain while subjects were completing a simple arithmetic task.
We reported that there were differences between those who
clearly had PCS and subjects who did not have an injury. Please
note that we use a treadmill test to assess and diagnose PCS and
in this study only included subjects who demonstrated exacerbation of symptoms during exercise (Leddy et al. 2011). Thus, we
have a relatively homogeneous sample of individuals with PCS.
Jonathan Silver’s article in this issue of BIP aptly points out the
importance of homogeneity in populations under study. So in
these individuals with PCS we found reduced metabolic activity
in certain areas of the brain: the cerebellum, the thalamus and
the posterior cingulate. This was an important finding because
these areas of the brain are important junction boxes for neural
activity and areas that are often the end points for inflammation.
When these individuals with PCS had recovered these differences from the normal (uninjured) controls disappeared.
The images of metabolic activity, however, provided more to
the story than we were able to include in the publication. The
following pictures of the brain activity for one subject illustrate
one very important observation. When a person with PCS is
asked to complete a task (in this case an arithmetic task) he/she
uses much more of his/her brain than uninjured controls. The
image on the right represents the subject completing the task.
8

BRAIN INJURY PROFESSIONAL

She is clearly focused on the task and the areas of the prefrontal
cortex most associated with working memory for arithmetic are
lit up and there is less activity in other parts of the brain. The
image below was taken after recovery. The image on the right
is the same subject while experiencing PCS. Her brain is lit up
in many places not associated with the arithmetic task and less
noticeably lit up in the areas of the brain associated with the task.
The image on the left is essentially indistinguishable from the
image of the healthy controls.
Image 1
PCS Subject after recovery

PCS Subject while symptomatic

It is very interesting that this person completed the arithmetic task with the same degree of accuracy when suffering from
PCS as when she was recovered. This was the same for all of the
subjects. She was slightly slower at completing the task during
the PCS period but only by a few milliseconds. However, as illustrated in the figures, when suffering from PCS she used much
more brain activity to accomplish the task. We think this provides an explanation for the fatigue that people with PCS report
when they carry out normal daily activities. Their brains are
simply inefficient and use considerably more brainpower to accomplish what is a relatively simple task for the healthy controls.
There are several other researchers that have used similar imaging techniques to study the brain activity in those with persistent concussion effects (Chen et al., 2008; Lovell et al., 2007).
Much like us, they reported on the areas of the brain that were

less active but did not report on the hyperactivity we observed.
Alain Ptito, one of the researchers doing similar work, was once
presenting at the same conference we were so we asked him if
he and his group observed the same phenomenon that we did;
namely, hypermetabolic activity rather than focused activity. His
answer: “absolutely”. However, as it turned out, they did not
report the finding for the same reason we did not. We did not
find a statistically significant finding.
Every subject with PCS had this hypermetabolic activity.
However, the pattern of superfluous activity was different for
each subject. It was as if the brain was unsure what parts of
the brain were necessary for the activity at hand and just fired
randomly. Statistical tests look at groups of subjects and compare activity in different regions of the brain (defined as voxels,
described below). Despite finding each subject showing hyperactivity the collective picture did not show hyperactivity consistently in the same voxels of the brain. Hyperactivity in one
subject’s voxels counter-balanced the hyperactivity in another
subject’s voxels and wiped out the effect. Thus a clearly observable finding was not a reportable finding.
Functional imaging and other forms of advanced imaging are
made possible, in part, because of the improvements in imaging but
also because of the advancements made in statistical procedures that
allow for evaluation of differences based on very large numbers of
observations. Imaging produces microdata on very small areas of
the brain called voxels. A voxel is a cube (about 3mm on each side)
and houses about a million brain cells. There are approximately
130,000 voxels in a typical scan. The chance of false positives (seeing activity when there is none) is very high since there are so many
voxels, but the statistical procedures account for multiple comparisons. Bottom line, our hyperactivity observation that was so obvi-

ous and so important clinically was not statistically significant.
The other really important observation from our study is that
some of the subjects were completely recovered by the time we
conducted the second set of scans and those that were recovered had brain scans that were indistinguishable from the healthy
control subjects. Although evaluating whether scans are similar
is even more complicated than determining differences (from a
statistical point of view) it did appear that recovery in terms of
symptoms and physiology is matched by recovery in terms of
brain metabolism.

About the Authors

John Leddy MD FACSM FACP is an Associate Professor of Clinical Orthopedics, Internal Medicine, and Rehabilitation Sciences at the University
at Buffalo School of Medicine and Biomedical Sciences. He is the Medical
Director of the University at Buffalo Concussion Management Clinic, which
is the first center in the United States to use a standardized exercise treadmill
test to establish recovery from concussion and to use controlled exercise in
the rehabilitation of patients with prolonged concussion symptoms. He is
published in the fields of orthopedics, physiology, nutrition, concussion and
post-concussion syndrome. His primary research interest is the investigation
of the basic mechanisms of the disturbance of whole body physiology seen in
concussion and how to help to restore the physiology to normal and so help
patients to recover and safely return to activity and sport.
Barry Willer received his PhD in Psychology from York University (Canada) in 1975. Since this time he has been a Professor of the medical school
of the State University of New York at Buffalo. His research interests have
focused on psychological and social issues associated with traumatic brain
injury. He authored the Community Integration Questionnaire, which is
internationally recognized for assessment of participation. Dr. Willer was
lead author of the first return to play guidelines after concussion adopted
by the International Olympics Association. He currently heads a team of
researchers examining emotional regulation following brain injury.

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9

Structural Magnetic Resonance Imaging in Concussion

By Paul Polak, MASc

Concussion and post-concussion syndrome (PCS) is currently
a very active area of research for neurologists, sports medicine
doctors, behavioral scientists and medical imaging specialists. PCS can lead to depression, irritability, cognitive decline,
chronic headaches, dizziness, and aggressiveness. (McCrory et
al. 2009) Moreover, the recent tragic outcomes for some professional athletes (i.e. former NFL linebacker Junior Seau, former NHL defenseman Wade Belak) have been linked to the
concussions and sub-concussive blows they experienced in their
careers. Typical clinical magnetic resonance imaging (MRI) is
often insensitive to the symptoms of concussion and PCS, and
thus there is a vital need for research to aid in the prognosis and
treatment issues surrounding acute concussions. Some structural MRI techniques show promise in detection of concussion
injuries, and these can be used to qualitatively or quantitatively
assess the brain’s components – this can be palpable (quantities
of white and grey matter tissue), or indirect (evaluation of myelin integrity in white matter). In MRI, we use the resonance of
hydrogen atoms in a strong magnetic field and manipulate various pulses to create image contrast between tissue types, for instance between grey and white matter, or between healthy tissue
and tumor. In a 2-dimenstional image such as on a flat-screen
TV we refer to the smallest possible element as a pixel; however,
MRI data is 3-dimensional and thus the smallest element is referred to as a volumetric pixel, or simply voxel.
Despite the considerable interest in concussion research in
the last few years, the mechanisms have been investigated for
some time. A paper by Holbourn (Holbourn 1945) theorized
that rotational forces in concussion events cause the various
brain tissues to move at different relative speeds. It is believed
that the acceleration/deceleration of these tissues can cause
10 BRAIN INJURY PROFESSIONAL

shearing forces on the axons. White matter and grey matter
differ in their densities and have varying mechanical properties – white is in general stiffer then grey, but it also has more
variability in its composition. (Van Dommelen et al. 2010) In
a concussion event the denser tissues can slide over each other,
putting strain on the axons which connect these tissues together.
This stretching and straining can damage the myelin layer surrounding the axons, causing it to weaken or break. The term
used to describe this myelin breakage is diffuse axonal injury
(DAI) and it was first investigated in car accident victims by
Strich, (Strich 1956) where it was observed that post-mortem
brain tissue samples indicated widespread and non-focal degeneration of the white matter and loss of nerve fibers.
Diffusion Tensor Imaging (DTI) is an advanced MRI technique that can be used to quantify water diffusion in tissue. The
technique works by comparing a standard clinical T2-weighted
MRI scan (referred to as the non-diffusion, or b=0 scan) with an
identical one that has been prepared by a magnetic diffusion gradient in a particular direction. This diffusion scan indicates preferential movement of water in that direction by a loss of image intensity – the more the diffusion, the less the signal. By using at least 6,
but often 15 or more diffusion directions, a very complete picture
of diffusion in the brain can be determined. The DTI analysis determines at every voxel the 3 primary diffusion directions and their
magnitudes are ranked such that λ1, λ2, and λ3 represent the order
from most to least. The primary magnitude λ1 is also referred to as
the axial diffusivity (AD), and the average of λ2 and λ3 is denoted
as the radial diffusivity (RD). Because myelin restricts diffusion,
healthy axons exhibit anisotropic diffusion whereby water is more
likely to move along the axon (AD) than perpendicular to it across
myelin (RD) (Figure 1). We assess the relative contribution from

Figure 1

Visualization of a DTI scan of a human brain

Depicted are reconstructed fiber tracts through the mid-sagittal plane. White box gives a zoomed view of one tract,
with depicted axial diffusivity (AD) measurement along the tract, and radial diffusivity measurement perpendicular. The
magnitude of AD would be much greater than RD for this tract and for any in healthy white matter tissue. Image is
author’s own work based on work attributed to Thomas Schultz, and used under the Creative Commons AttributionShare Alike 2.5 (CCA-SA-2.5) Generic license.

these two measures by fractional anisotropy or simply FA. FA
is a score from 0 to 1, where 0 indicates perfectly isotropic diffusion (like we might expect to find in cerebrospinal fluid) and
1 is perfectly anisotropic. These measures can be used to evaluate myelin integrity, since any damage to this membrane allows
water diffusion across the axon, leading to increased radial diffusivity and decreased FA values. Since concussion has been
linked to DAI, there has been interest in using DTI in MRI
techniques in order to investigate axonal integrity, with varying results, (Mayer et al. 2010; Messé et al. 2012) although one
paper found correlations between the number of damaged white
matter structures and reduced performance on cognitive tests.
(Niogi et al. 2008)
These previous works often analyzed concussed patients on
a group-wise basis by comparing a cohort of patients with a
healthy group of matched controls. A recent technique analyzing subjects on an individual basis has determined that heterogeneous, localized regions of significantly different FA “potholes” are apparent in concussed patients and may linger for
weeks or months after the concussion event. (M. L. Lipton et
al. 2012) This type of analysis relies on comparing individual
concussed subjects with a group of matched controls in order
to find brain regions where the DTI FA values are significantly
different from the control mean values. The desire to investigate DTI in patients on an individual basis stems from a very
practical insight into concussion – since each method of injury
for concussion subjects is unique, the damage they present will
be unique. Moreover, if concussions result in DAI because of
the shearing and stretching of fibers as brain matter moves and
slides over other tissue, each patient could present a unique,
spatially heterogeneous amount of DAI. Therefore it is quite
possible that different concussed patients will thus display different spatially heterogeneous FA potholes, and as such any
attempt to compare patients at a group-wise level would only
“wash-out” any differences that would be apparent individually.
Despite the differences that might be expected for these reasons,

Figure 2

Potholes analysis on a concussed patient

Potholes analysis on a concussed patient, with axial, coronal and sagittal views given from top to bottom. Right side of
head indicated with R. Red-yellow areas indicate areas of low FA potholes and blue-light blur indicate regions of high
FA values. Splenium of corpus callosum most obviously affected area.

concussed patients often present altered FA in similar regions in
the brain such as in the corpus callosum. The reasons for this
are related to the structure of fibers in the brain – the corpus
BRAIN INJURY PROFESSIONAL

11

callosum is the major “highway” through which the two hemispheres of the brain communicate, and thus it has the greatest
densities of fibers running through it. Pothole analysis in one of
our recent studies (Figure 2) confirms this region’s susceptibility
to FA alterations, along with other regions such as the brainstem, anterior and superior corona radiata, internal and external
capsules, and the thalamus. Although this methodology indicates significant decreases in FA, which would be in agreement
with a theory of myelin damage, it also shows many areas of
increased FA values. Recent research has postulated that this
phenomenon may be due to axonal swelling post-injury which
decreases RD in these voxels, but the actual explanation remains
unknown. Longitudinal analysis of these potholes indicates that
they do not necessarily resolve over time even as symptoms alleviate, but the brain’s adaptability and plasticity is a confounding component. More research into DTI, PCS and cognitive
recovery needs to be conducted in order to draw conclusions.
Magnetic resonance spectroscopy (MRS) is a technique used
to measure hydrogen metabolites in the brain. These appear not
as an image, but rather on a frequency spectrum, with the peaks
indicating the concentrations of various molecules, such as Nacetylaspartate (NAA), choline, creatine, lipids, glutamate and
glutamine. A recent study by Vognozzi (Vagnozzi et al. 2010)
investigated MRS in the anterior corona radiata in 40 concussed
athletes, where the authors investigated the ratios of NAA to creatine and choline concentrations. NAA is a particularly interesting metabolite, since it is usually considered to be a biomarker
for neuronal integrity, while creatine and choline are useful since
their concentrations do not change as a result of concussion. The
papers’ findings concluded that despite each athlete reporting
themselves symptom free 3-15 days post-injury, the MRS analyses indicated that the average athlete did not return to normal
NAA to creatine or NAA to choline ratios until 30 days postinjury. The athletes were compared to an age and sex matched
cohort of controls, and did not participate in their sports until
the completion of the study. The result of future concussions
on NAA levels for already concussed patients remains unknown.
One quantitative technique used in neurological research
is voxel-based morphometry (VBM) analysis, which is used to
determine the volumes of specific tissues in the brain. First,
a high-resolution MRI brain scan is obtained, after which the
images are segmented into their 3 healthy types – cerebrospinal fluid appears darkest, white matter tissue is the brightest,
and grey matter in between. By scanning the same patient over
time, a longitudinal analysis can be derived indicating which
tissues have changed in volume and by what amount. VBM
analysis usually involves the intermediate step of registration,
which means aligning the subsequent VBM scans to the initial
before performing the volumetric analysis. Gale et al. found in
2005 grey matter atrophy in patients with a history of traumatic
brain injury, and this atrophy was correlated with performance
in a cognitive attention test. (Gale et al. 2005) Unfortunately,
many neurological disorders and processes are correlated with
atrophy, including multiple sclerosis, Alzheimer’s syndrome, dementia and even normal aging, making VBM analysis a sensitive, but non-specific, technique when dealing with traumatic
brain injury.
Susceptibility weighted imaging, or SWI, is an advanced
MRI technique whose contrast is driven in part by a tissue’s
magnetic properties, such as the paramagnetic properties of
12 BRAIN INJURY PROFESSIONAL

deoxygenated blood in veins compared to arterial blood. It is
useful because of its ability to visualize hemorrhage accurately,
especially in cases where microbleeds are not evident with more
conventional MRI scans. For chronic cases SWI will be sensitive
to the iron deposition that can occur around prior hemorrhages.
While useful for revealing the extent of traumatic brain injuries,
SWI is not necessarily specific enough in terms of diagnosis or
prognosis, because the role of bleeding in treating concussion
patients is not clear. SWI’s usefulness is often lessened in cases
of minor traumatic brain injuries because these injuries may not
be accompanied by hemorrhage. SWI is generally more effective at higher MRI magnetic field strengths (3 Tesla), but its role
in acute concussion cases is not entirely clear.
Structural imaging in concussion research examines the
fundamental arrangement of brain tissue in order to detect differences in the concussed patients compared to their baseline
normal state. Symptomatic concussion patients often show no
structural abnormalities in typical clinical MRI, and thus there is
a need for advanced imaging techniques. Concussion events are
believed to cause DAI, and while DTI, MRS, SWI and atrophy
measurements have all been used in concussion research, DTI is
currently receiving the most attention due to its ability to measure axonal and myelin integrity. Research into concussion and
PCS is ongoing, and structural MRI is expected to be at the forefront of new methods and analyses into the prognosis of patients.
References

Paul Polak, M.A.Sc is a MRI physicist at the Buffalo Neuroimaging Analysis Center. In that role he designs and develops novel pulse sequences, image reconstruction techniques and analysis software towards investigating
neurological disorders. His graduate work in 2008 focused on designing
an ultra-fast MRI pulse sequence which utilized pseudo-random trajectories. In 2009 he served at the Sunnybrook Research Center in Toronto,
ON with a team investigating minimally-invasive, MR-guided focused
ultrasound therapy for prostate cancer, and was instrumental in the first
successful human trial. He has also worked for several years as a software
consultant with experience across a wide variety of languages and platforms. He has a keen interest in examining advanced imaging techniques
in sports-related concussions.

BRAIN INJURY PROFESSIONAL

13

Functional imaging for concussion
assessment and research
by David S. Wack, PhD

We use the term functional imaging to separate the purpose of
the performed medical imaging from that of structural. With
functional imaging, we are concerned with physiological values
such as blood flow or metabolism. The physiologic values
are often combined with structural images to give someone
examining the image structural landmarks to localize and
interpret the image. Functional imaging can be carried out
with most of the major imaging modalities. Within Magnetic
Resonance Imaging (MRI), functional MRI (fMRI) has been
used for tens of thousands of studies to assign neural correlates
with particular cognitive tasks. For instance, this could be to
localize which region of the brain is responsible for listening to
a tone, or focusing on an object. This notion is carried much
further to include comparisons of how different groups might
perform different tasks. It is also extended to imaging where
the patient performs no task at all. In this paradigm, several
hundred scans (each scan lasting only a couple of seconds) are
used for an analysis to determine which regions of the brain are
correlated with one another, and gives the researcher or clinician a
network view of the brain. An underlying simplistic assumption
of functional brain imaging is that the brain doesn’t have reserve
storage. That is if there is an increase need in oxygen, then that
need is met through an increase in blood flow to that region.
A perfusion study can be performed with either MRI or
Computed Tomography (CT) and typically generates at least four
different physiologic parameters of interests. These parameters
are calculated from an analysis of an injected tracer such as
Iodine if using CT, or Gadolinium if using MRI. By examining
the concentration of tracer at each location of the brain, for
many time points, we can form a “Time Activity Curve” (TAC)
for each volume element of a scan (voxel). A simple and very
sensitive parameter that is calculated for each TAC is the Time
To Peak (TTP), which is simply the time that it takes the injected
tracer to reach the peak activity at each voxel location. Locations
where there is a noticeable delay in perfusion may indicate that
there is an underlying problem in that area. Other parameters
that can be calculated include Cerebral Blood Flow (CBF) and
Cerebral Blood Volume (CBV), and finally Mean Transit Time
(MTT), which is the mean time for an element of the injected
14 BRAIN INJURY PROFESSIONAL

tracer to pass through the tissue region.
A difficulty with Gadolinium and Iodine tracers is that in
most cases neither crosses the Blood Brain Barrier (BBB), which
is to say that the tracers are not taken up into the neural cells.
Hence these tracers only occupy a small percentage of any voxel,
typically between 2 to 8 percent. In contrast, Xenon which can
be used for inhalation with CT imaging does cross the BBB.
By only typically occupying a small percentage of volume, the
Gadolinium and Iodine tracers have a disadvantage for the
effective signal of the tracer. An advantage however is that it is
readily apparent as an image hyper-intensity when either tracer
does cross the BBB. This is the situation with what are commonly
referred to as “Gad enhancing lesions”. Likewise, either tracer
still remaining or increasing at a location after a minute or more
can indicate a bleed.
Positron Emission Tomography (PET) is somewhat similar
to perfusion MR or a CT study in that PET always requires an
injected tracer. However, PET is fundamentally different because
the signal that is measured with PET originates from the tracer.
PET can use a variety of radio-isotopes, which typically have halflives ranging from a couple of minutes to a couple of hours. That is,
what can be measured from an injected tracer decays exponentially
with time. The radio-tracers are created using a cyclotron. Hence,
especially for shorter half-life tracers, the cyclotron typically needs
to be close to the scanner. Because of the complexity and man
power needed in creating the isotope, PET is typically a “during
normal business hours” imaging method.
In the acute setting a CT scanner may be used to assess brain
injury, if the patient meets selection criteria based on factors
including loss of consciousness, amnesia, vomiting, and Glasgow
Coma Scale. A CT scan can be performed with no worry of
metal within the patient’s body such as a pacemaker, or recently
placed screws etc., that could prohibit an MRI in some cases. If
a tracer is used with CT, such as Iodine, this is readily available
“off the shelf ”, as opposed to radioactive tracers used for PET.
Furthermore, a CT scan is very fast, and the majority of the
time is spent simply getting the patient positioned on the gantry.
A high resolution structural image can then be acquired in a
few seconds. If Iodine or another tracer is used, the scanning

acquisition typically lasts 1 minute, which is more than enough
time for the tracer to pass through the brain in most cases. The
TAC of the tracer uptake is used to determine the TTP, CBF,
CBV, and MTT parameters. CBV is essentially the fraction of
the tissue voxel that is occupied by the blood, and typically has
the best noise characteristics of the parameters. Having a measure
of the tracer from an artery allows absolute or quantitative values
(rather than relative values) of CBV and CBF to be calculated.
A bleed can be detected by an accumulation of tracer after
a period of time, and can also be seen through subtle change in
image intensity on an unenhanced (non-contrast) CT. If a bleed
is detected, the patient may not have a concussion, but is rather
in a more serious condition. An advantage of using MRI imaging
with Gadolinium as a tracer to determine CBF and CBV is that
radiation exposure is not a concern. MRI may therefore be ordered
in the days following a concussion by the patient’s physician.
There are methods that use MRI that are functional without
using a tracer. Blood Oxygen Level-Dependent (BOLD) fMRI
is able to detect subtle changes in the oxygenation level of the
blood. The underlying principle is that in response to performing
a given cognitive task (that can be performed in the scanner),
more oxygen is required in regions of the brain performing the
task. This is accomplished naturally by the brain, resulting
in an increase in the blood flow and a decrease in the relative
amount of deoxyhemoglobin and the decrease in the magnetic
susceptibility of tissue at the imaged location, this in turn results
in an increase the MRI signal at the corresponding voxel. Arterial
Spin Labeling is another MRI method which essentially tags the
blood with a “spin” at one time, and examines the percentage of
tagged blood that remains after a small time. Chen et al. found
increases in BOLD activation for athletes with concussion vs.
controls in the dorsolateral prefontal cortex.1 We demonstrated
possible neural differences between recovery methods.2
As care of a patient moves to the post-concussion stage,
modalities such as PET and SPECT, which is another nuclear
medicine modality, are often considered. Because there are a variety
of tracers available for use, PET or SPECT can measure biological
function in a variety of ways. The most common tracer used with
PET is Fluorodeoxyglucose F18 (FDG). FDG is well known
because it is commonly used for the diagnosis and staging of cancer,
since tumors have a high metabolic activity. FDG is readily taken
into neural cells and because of the underlying kinetics remains for
a relatively long period of time before exiting. FDG imaging of
the brain can reveal regions that have become relatively hyper or
hypo metabolic, and reveal an underlying issue. An advantage of
F18 based compounds used as tracers is that the half-life of ~110
minutes allows a business model which allows the transport of the
tracer to different nearby cities. Bergsneider et al.3, followed three
phases of concussion recovery using FDG: initial hyperglycolysis,
followed by decreased activity which resolves about 1 month after
injury, followed by a return to normal. However, they found poor
correlation between disability ratings and scan activity.
Carbon 11 based PET compounds are also commonly used
for imaging research, for example Fallypride and Raclopride
can be used for the assessment of dopamine uptake. These
tracers may be especially useful for assessing attention4, which
has been known to be problematic with patients recovering from
concussion. Pittsburgh Compound B is yet another common
PET tracer, which has been used extensively for detection of

increased amyloid deposition in Alzheimer’s patients.
Chronic Traumatic Encephalopathy (CTE) is a progressive
degenerative disease that has been closely associated with boxing
as so called “punch drunk”. CTE has been found in players
from several contact sports including football and hockey, and
soldiers exposed to concussive injuries. Sufferers of CTE have
brain atrophy and enlargement of ventricles, both of which can
be indicative of an underlying issue, not specific to CTE. CTE is
associated with tau proteins.5 In recent work using PET imaging
with tracer FDDNP, which binds to tau and beta amyloid, Small
et al.6 found significant uptake in some of the five former NFL
players that they scanned. They argue that the uptake is likely
due to tau as opposed to amyloid based on the pattern of uptake.
Zhang et al. have performed preclinical in vivo studies with
[18F]-T808 which targets tau rather than Amyloid aggregates7.

Conclusion

The premise behind functional imaging is that it is not enough
to map out the underlying anatomy of a patient. Rather, we are
acutely interested in the underlying physiology of the imaged
tissue. There are multiple physiologic measures that we may be
interested in such as blood flow, blood volume, metabolic rates
of glucose, uptake values, and binding potentials of various
compounds. There are many corresponding tracers which can
be injected that enable the quantitation of activity of a tracer
over time. However, there are also non-tracer methods such as
ASL or BOLD fMRI. In total, each method offers a specialized
glimpse of the underlying pathology that would otherwise be
missing if only a structural MRI or CT was used.
About The Author

Dr. David Wack is a Research Associate Professor in the Department of
Nuclear Medicine at SUNY at Buffalo. Dr. Wack’s work specializes on
noise reduction, segmentation, and parameter estimation algorithms for
medical imaging. He has performed extensive work with MRI, PET, CT,
and EEG imaging, and is currently focused on applications for improving
imaging for concussion, stroke, and functional auditory imaging. Dr.
Wack has published and presented algorithms for pattern recognition, advanced methods of smoothing, and non-parametric de-noising of medical
imaging time series. These methods have been utilized to improve physiological parametric images such has blood flow, blood volume, and binding
potential. He has co-authored over 30 peer-reviewed research articles.

Restore Neurobehavioral Center is a residential, post acute healthcare organization dedicated exclusively
to serving adults with acquired brain injury who also present with moderate to severe behavioral problems.
Services range from intensive inpatient neuro-rehabilitation and transitional community re-entry services
to long term supported living services. Restore Neurobehavioral Center, located in a suburb north of Atlanta,
is the site of our inpatient post acute neuro-rehabilitation program as well as one of our supported living
sites. We operate two other community living sites, Restore-Lilburn (GA) and Restore-Ragland (AL).

The Toral Family Foundation (TFF) in partnership
with UF Health will host the “TBI: Changing the
Game Conference” — an event to educate,
inspire and connect medical professionals on the
topic of Traumatic Brain Injuries (TBI) and it’s
relevancy to all practicing clinicians.
KEYNOTE SPEAKER
Sanjay Gupta, MD

A Historical Perspective on
Advanced Neuroimaging
in Clinics and Courts
by Hal S. Wortzel, MD

The aphorism that history repeats itself often holds true. This is
readily apparent in the world of science and medicine, where the
latest and greatest discoveries and/or technologies may be received
with premature enthusiasm before the establishment of a sufficient or credible scientific basis, eventually yielding disappointment when initial promises go unrealized. Illness often breeds
desperation, making patients and individuals with various forms
of medical and/or neuropsychiatric illness especially susceptible to
the promises that occasionally accompany efforts to commercialize new technologies. Litigation, which entails an adversarial environment, and is driven largely by the question of compensation,
can lead to early transgressions and/or controversies regarding the
interpretation and use of such technologies. Hence, medicolegal
experts serve an important role in preserving the scientific integrity of emerging technologies, and neuroimaging is no exception
(Wortzel, Kraus et al. 2011).
Although it often seems that the controversies surrounding
neuroimaging in courts of law is a new phenomenon the problem
is actually a historically well-established one. History offers up
some rather illustrative and dramatic examples of neuroimaging
and neurodiagnostic techniques being deployed in a manner that
have not withstood the test of time. While many Americans know
the Jack Ruby shot John F. Kennedy’s assassin, far fewer know that
he claimed to have done so during a seizure, and that controversy
surrounding the interpretation of a “rhythmic temporal theta
burst” pattern on electroencephalography (EEG) was at issue
in a trial occurring nearly half a century ago (Gutmann, 2007).
A defense expert, based upon the EEG evidence, and despite a
host of clinical and historical factors suggesting otherwise, offered
testimony that Ruby was unable to distinguish right from wrong
18 BRAIN INJURY PROFESSIONAL

at the time of his offense. The guilty verdict handed down by the
jury was later overturned on appeal, and Jack Ruby died of cancer
while awaiting a new trial. Importantly, the psychomotor variant
of epilepsy alleged at Ruby’s trial is now referred to as rhythmic
temporal theta bursts of drowsiness and “as a type of epilepsy, has
become a historical footnote” (Gutmann, 2007). While violent
criminal acts are seldomly the result of seizures, there remain
genuine instances of ictal and peri-ictal behaviors resulting in
otherwise criminal behaviors, and such defendants should have
legitimate affirmative defense opportunities available to them.
Unfortunately, abuses of the epilepsy defense and scientifically
inappropriate introduction of EEG evidence have arguably yielded
an environment of skepticism that makes even the most legitimate
of claims difficult to successfully litigate (Wortzel, Strom,
Anderson, Maa, & Spitz, 2012). There are potential consequences
to “crying wolf,” and it is thus appropriate to reflect upon the
potential long-term ramifications of contemporary medicolegal
uses of neuroimaging, and what the implications might be for
future criminal defendants and/or plaintiffs with real illness/injury.
Another striking example from history is the case of John
Hinckley, who was found to be legally insane when he attempted
to assassinate President Ronald Reagan. The case and its outcome
were quite controversial, and disconcertion surrounding this
verdict is frequently cited as inducing widespread change in legal
definitions around the nation, in particular the abandonment
of volitional prongs to legal criteria for insanity. How much did
neuroimaging evidence influence the jury offering this verdict, a
verdict which arguably had far-reaching societal consequences,
resetting the bar for legal insanity at a higher level? While we do
not know the answer to that question, we do know this: claims/

testimony that Hinckley’s CAT scan of the brain evidenced his
diagnosis of schizophrenia have not withstood the test of time, and
thirty years later we remain without a diagnostic imaging study for
that neuropsychiatric disorder.
The next generation of neuroimaging/neurodiagnostic
controversy has arguably surrounded the clinical and medicolegal
commercialization of quantitative electroencephalography
(qEEG)(Arciniegas, 2011; Coburn, Lauterbach, Boutros et al.
2006) and single photon emitted computed tomography(SPECT)
(Adinoff & Devous, 2010; Wortzel, Filley et al. 2008). Both
of these technologies feature considerable merits, and each
has been used effectively in numerous areas of research to
advance our understanding of the human brain and various
forms of neuropsychiatric illness. Both have also been heavily
commercialized, and purported to have diagnostic ability/accuracy
that critics are quick to refute. The Committee on Research of
the American Neuropsychiatric Association identified that: “A
pivotal question remains unanswered concerning the actual
clinical utility of qEEG and related electrophysiological methods:
are the techniques sufficiently sensitive and specific to answer
practical clinical questions about individual patients suffering
from recognized psychiatric disorders?”(Coburn, et al., 2006)
The committee also recognized real substance regarding fears
that unsophisticated practitioners might use the technology to
substitute for (instead of augment) clinical diagnosis. They note a
history involving widespread commercialization, including vendors
aggressively marketing qEEG as virtually a standalone diagnostic
test. Despite the number of published investigations espousing the
merits of qEEG, the committee identified “several broad problems”
regarding methodology that reflected “the difficulty of translating
the methodological freedom of research into the uniform
standardization necessary for clinical application.” Readers are
referred to the committee’s report for additional details regarding
methodological concerns/limitations; there are many (Coburn, et
al., 2006). Notably, Arciniegas (Arciniegas, 2011) offers a detailed
review of the literature directly addressing the issue of EEG and
qEEG as applied to persons with mild traumatic brain injury
(mTBI); “qEEG discriminant functions are of debatable value
in the clinical or forensic diagnostic evaluation of persons with
mTBI. Having said this, it is important for clinicians and forensic
practitioners to remain mindful that this is a matter of controversy.
Clinicians involved in the care and medicolegal evaluation of
individuals with mild TBI are advised to consider all arguments
regarding this technology before deciding on the advisability and
value of using qEEG” (Arciniegas, 2011).
A remarkably similar history of commercialization
and controversy surrounds SPECT imaging as applied to
neuropsychiatric disorders (Adinoff & Devous, 2010; Wortzel,
et al., 2008). That controversy is well illustrated in an exchange
of letters(Adinoff & Devous, 2010; Amen, 2010) that featured
in the American Journal of Psychiatry. Adinoff and Devous
offer a compelling argument that early misapplications of
neuroimaging, if left unchallenged, may poison the waters such
that when the technology becomes appropriate for meaningful
clinical application its history of misapplication erects untenable
barriers to acceptance in clinical and medicolegal venues. This
prediction rings familiar, being not unlike the previously described
unfortunate history surrounding EEG and epilepsy in criminal
courts. My own early experience with SPECT, dating back to

fellowship days in neuropsychiatry, featured a couple troubling
clinical encounters involving SEPCT being misused to substantiate
otherwise untenable diagnostic formulations, and in association
with active litigation. Such experiences prompted a review and
analysis of the subject of SPECT as applied to mild TBI by the
Neurobehavioral Disorders Program at the University of Colorado
(Wortzel, et al., 2008) and subsequent exposures continue to reveal
that this technology is not infrequently deployed to “prove” brain
injury in isolation of or in contrast to clinical presentations and
history, often times in association with interpretive reports that
fail to live up to existing ethical reporting requirements (Society
of Nuclear Medicine, 2002; Society of Nuclear Medicine Brain
Imaging Council, 1996). This is not to say that SPECT is without
its merits or potential clinical utilities (there are typically legitimate
arguments to be had on both sides of most controversies), but
it is reflective of an irrefutable historical trend: neuroimaging
technologies carry the potential for misapplication, commercial
and/or medicolegal.
Technology’s advances has brought about even more modern
neuroimaging techniques, some yielding truly spectacular
images of the brain that are unlike anything previously available.
Should the cutting-edge nature of these techniques or the
stunning quality of associated images cause us to forget our
history lessons? Newness and youth are fleeting conditions,
and EEG once enjoyed that same status much as function MRI
(fMRI), Positron Emission Tomography (PET), or Diffusion
Tensor Imaging (DTI) do today. With this new generation
of neuroimaging comes the next wave of controversy. As with
generations past, there are worthwhile arguments proffered by
both camps. But history and persisting limitations (see points of
caution offered by Dr. Jonathan Silver in his article in this current
issue) warrant (if not mandate) healthy skepticism regarding the
ability of these latest modalities to differentiate between various
neuropsychiatric conditions, or even to discern “abnormal”
from what is an extraordinary broad range of inter-individual
differences when it comes to brain structure and metabolism
(Mayberg, 1996; Reeves, Mills, Billick, & Brodie, 2003; Silver,
2012; Wortzel, et al., 2008; Wortzel, et al., 2011). It remains
prudent to recognize that these new neuroimaging techniques
carry the potential for misapplication in medicolegal settings,
with perhaps previously unrealized influential power predicated
upon eye-catching technology and images.
In light of the existing controversies surrounding the use of
various forms of advanced neuroimaging, especially in medicolegal
settings typically involving single subject applications, guidelines
that simultaneously facilitate legitimate uses while minimizing
the risk and/or impact of misuses are needed. A tremendous
void has recently been filled by a multidisciplinary consensus
conference regarding the ethical use of neuroimaging in medical
testimony held on December 7 and 8, 2012 at Emory University.
The report (Meltzer, Sze, Rommelfanger et al. 2013 in press)
describes the process involving an interactive forum and a highly
select group of experts including: neuroradiologists, neurologists,
forensic psychiatrists, neuropsychologists, neuroscientists, legal
scholars, imaging statisticians, judges, practicing attorneys, and
neuroethicists.
While the entire report should be required reading for all
those who encounter neuroimaging in medicolegal contexts,
a few particularly salient aspects warrant mention herein. The
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BRAIN INJURY PROFESSIONAL

21

report explicitly notes that advanced imaging techniques (fMRI,
DTI, PET, and SPECT) are used “only in a few clinical settings”
wherein sensitivity and specificity have been established.
“Further, the applicability of normative imaging databases
(typically comprising young, healthy subjects) in courtroom
testimony is questionable. We also note that the use of normative
imaging databases for comparisons to individual subjects
for the purpose of expert witness testimony may constitute
an inappropriate use of materials collected from research
subjects” (Meltzer, et al., 2013). This latter point warrants some
additional comment. Normative databases are built from data
collected from individual participants. Conference attendees
expressed concern surrounding the likelihood that the consent
process surrounding such participation includes notice that the
normative database will be used for purposes other than research,
including potentially medicolegal applications. Furthermore,
participants are likely unaware that the normative database,
including their own individual data, may be sought from
opposing parties in legal contests to assess the fidelity of analyses
and interpretations offered. Participation for many reflects a
beneficent effort to contribute to the advancement of science
with the understanding that their own data will not be shared.
The decision to participate, and/or what constitutes appropriate
compensation, is potentially radically altered if/when normative
databases become part of a lucrative clinical and/or medicolegal
neuroimaging practice, and otherwise guarded individual data is
disclosed in medicolegal proceedings. Absent a consent process
that addresses these issues, the application of normative databases
obtained for research purposes to medicolegal endeavors raises
serious ethical concerns.
The report/conference explores a few select cases “that were
exemplary of use and abuse of neuroradiological data in the
courtroom,” and brain trauma was among them. In particular,
the controversy and potential pitfalls of DTI in this context are
highlighted:
This technique promises to offer unique insights into the
natural history of brain injury and potentially inform therapeutic
approaches. Yet the manner in which DTI data are acquired
produces findings that not only lack specificity, but also continue
to be highly variable across institutions and among researchers.
The American Society for Functional Neuroradiology (ASFNR)
has developed general guidelines for the acquisition and postprocessing of DTI data. But the rapidity of evolution of this
technique has contributed to the challenge of achieving true
standardization. At present, the ASFNR guidelines include a
suggested disclaimer in clinical reports of DTI and notes that
“it is critical that physicians basing clinical decisions on DTI be
familiar with the limitations and potential pitfalls inherent to the
technique”. Furthermore, the neuroradiology community has not
arrived at a consensus view of the value of DTI in (particularly
mild) head trauma. Non-specific patterns or findings obtained
with DTI prohibit the confirmation or diagnosis of mild TBI
with reliability. If DTI or other non-specific imaging findings are
introduced into legal evidence, the expert should offer alternative
explanations for the findings, including technical factors and
normal variation (Meltzer, et al., 2013).
The identification of the particular subject of DTI in TBI
litigation for exposition in this report reflects the degree of
controversy and concern surrounding this practice, and communal
22 BRAIN INJURY PROFESSIONAL

concern that transgressions are occurring. Notably, the report’s
statement regarding the lack of consensus regarding DTI’s utility
in cases of mild TBI suggests that general acceptance has yet to be
achieved, a statement that is not without precedent or importance
for considering the evidentiary appropriateness of DTI for mild
TBI litigation (Wortzel et al., 2011).
In an effort to facilitate appropriate medicolegal applications
of neuroimaging while mitigating the potential for abuse, the
report offers proposed standards that “may both serve to guide
subspecialty societies like the American Society of Neuroradiology
and inform the legal community.” The proposed standards include
(Meltzer, et al., 2013):
1. Experts should present all relevant facts available in their
testimony, ensure truthfulness and balance, and consider
opposing points of view
2. Experts should specify known deviations from standard
practice
3. Experts should have substantive knowledge and experience
in the area in which they are testifying
4. Experts should use standard terminology and describe
standardization methods and the cohort characteristic
from which claims are determined, where applicable
5. Nonvalidated findings that are used to inform clinical
pathology should be approached with great caution
6. Recognized appropriateness guidelines should be used to
assess whether the imaging technique used is appropriate
for the particular question
7. Experts should avoid drawing conclusions about specific
behaviors based on the imaging data alone
8. Experts should be willing to submit their testimony for
peer review
9. Experts should be prepared to provide a description of the
nature of the neuroimages (e.g., representational/statistical
maps when derived from computational postprocessing of
several images) and how they were acquired
10. Raw images and raw data should be made available for
replication if requested
11. Experts should be able to explain the reasoning behind
their conclusions
12. False positive rates should be known and considered if the
expert’s testimony includes quantitative imaging
13. Experts should be prepared to discuss limitations of the
technology and provide both confirming research as well
as disconfirming studies
The importance of these standards is difficult to overstate. While
somewhat similar guidelines have been published previously
(largely for functional imaging techniques) (Society of Nuclear
Medicine, 2002; Society of Nuclear Medicine Brain Imaging
Council, 1996), the extent to which such standards have
been embraced by those offering such testimony, or enforced
by evidentiary gatekeepers, has been rather disappointing.
Fortunately, the imminent publication of these new guidelines
(representing consensus from truly multi-disciplinary proceedings)
represents a renewed opportunity for medical and legal professions
to meaningfully adopt and impose such guiding principles. These
standards serve to protect the integrity of both medical science and
legal proceedings, and thus ought to be embraced by all who aspire
towards virtuous medicolegal practice.

About The Author

Dr. Wortzel graduated from Amherst College
majoring in Biology in 1996 and then went on to
medical school at NYU, graduating AOA in 2001.
He completed his training in general psychiatry
at the University of Colorado in 2005, serving as
Chief Resident for the University’s Outpatient
and Consultation-Liaison services. Following residency, Dr. Wortzel completed the University of
Colorado’s Fellowship in Forensic Psychiatry. He
then went on to complete a two year combined
fellowship integrating the University’s Behavioral
Neurology & Neuropsychiatry Fellowship with
the VA’s MIRECC Fellowship in Advanced Psychiatry, emphasizing research in suicidology. He
now brings his combined training and skills as a
forensic neuropsychiatrist to the Denver VA’s
VISN 19 MIRECC, where he serves as director of
Neuropsychiatric Consultation Services and the
MIRECC Psychiatric Fellowship, and as the University of Colorado’s Department of Psychiatry,
where he serves as the Michael K. Cooper Professor
of Neurocognitive Disease, Director of the Neuropsychiatry Service, and as faculty for the Division of
Forensic Psychiatry. Current areas of clinical and
academic focus include aggression and suicide in
the context of PTSD and TBI, incarcerated veterans, and the application of emerging neuroscientific
tools to the legal arena.

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Structural and functional imaging are the two very different approaches to brain imaging currently available. Structural brain
imaging provides information about physical aspects of the brain.
Structural imaging techniques are not affected by neuronal activity. Computed tomography (CT) and magnetic resonance imaging (MRI) are the standard clinical methods. Many other structural brain imaging techniques are under development for clinical
use. Diffusion-based approaches, such as diffusion tensor imaging
(DTI) and diffusion kurtosis imaging (DKI), presently show the
most promise for imaging of TBI (Bigler & Maxwell, 2012; Shenton et al., 2012; Taber & Hurley, 2013). Functional brain imaging
provides information related to neuronal activity. Most functional
brain imaging techniques utilize indirect measures of neuronal activity, such as blood flow, metabolism, or oxygen extraction. Regional cerebral blood flow (rCBF) and regional cerebral metabolic
rate (rCMR) are the most commonly used measures. Although
there is a relatively close coupling between neuronal activity, rCBF
and rCMR, the activity-induced increase in blood flow is usually
more than what is required to meet the increased need for oxygen and glucose. If acquired under resting conditions, both rCMR
and rCBF provide a way to assess the baseline functional state of
brain areas. If acquired during performance of a mental or physical task, they provide a way to assess specific neuronal pathways or
structures with performance-related alterations in neuronal activity. This allows brain activity under specific cognitive or affective
conditions to be measured. Pharmacologic challenges are also utilized. Functional brain imaging techniques currently used in clinical practice include single photon emission computed tomography
(SPECT), positron emission tomography (PET), and magnetic
resonance spectroscopy (MRS). Functional imaging techniques
under development for clinical use include functional magnetic
resonance imaging (fMRI) and magnetoencephalography (MEG).
Research utilizing these techniques has provided insights into
multiple aspects of cognitive and emotional functioning, including learning, memory, emotional regulation, control of attention, and modulation of behavior. The vast majority of studies
are based on comparing groups of individuals with a specific disorder to groups of normal healthy individuals. Such studies have
identified functional impairments that commonly occur in par24 BRAIN INJURY PROFESSIONAL

ticular psychiatric conditions, such as major depressive disorder,
schizophrenia, obsessive-compulsive disorder, and attention deficit hyperactivity disorder. However, results often vary considerably across studies. Factors that are known to strongly influence
results are the differences across individuals in both preexisting
state and disorder-related symptoms. Thus, clinical applications
of functional brain imaging have been limited by the challenges
of translating insights based on group comparisons to understanding the individual patient. Unlike structural brain imaging,
functional brain imaging is highly state-dependent and therefore always changing. Many factors can influence scan results
of a particular individual on a particular day. Functional brain
imaging is particularly useful for identification of areas that are
structurally normal but functionally abnormal, the “hidden” lesions. Evaluation of the resting state also has shown potential for
prediction of treatment response in some conditions.

Clinical Indications for Brain Imaging
From the historic perspective, structural brain imaging has been
obtained after positive physical exam findings in order to “ruleFigure 1

Clinical history: An adult male (mid-20’s) suffered multiple bone and facial fractures resulting in prolonged unconsciousness. Residual symptoms at 2 years post injury include personality change, low frustration tolerance, impaired set
shifting, poor concentration, impaired attention, stuttering, and symptoms of depression and post traumatic stress
disorder.
Neuroimaging: Left. At 2 years after the event, multiple areas of DAI are clearly visible on T2 weighted MRI. An area
in the posterior white matter containing several DAIs is circled. Right. The area containing a single DAI has been
enlarged (x1000) to show the individual blocks that form the image. For a DAI to be visualized by neuroimaging, it
must change the signal intensity of multiple adjacent blocks, which typically are at least 1 mm per side. Thus, a DAI
must have a considerable volume to be visible on clinical imaging.

Figure 2

Added Value Example - SPECT Imaging

Clinical history: An adult male (mid-40’s) suffered a blow to the head from a piece of equipment. He later described
being dazed and confused immediately after the event, but he was able to drive himself home. He experienced a
progressive decline in functioning. New onset symptoms included problems with short term memory recall, stutter,
depression, and suicidal ideas. These symptoms were unresponsive to all medication trials.
Neuroimaging: Clinical MRI was unremarkable other than mild enlargement of the lateral sulcus in the temporal lobe.
SPECT identified areas of increased perfusion in the medial portion of the temporal lobe (circled), suggesting the
presence of a seizure focus that was located too deep in the brain to be identified with surface electroencephalography.
Clinical Management: Aggressive seizure treatment cleared all of the new onset symptoms including the stutter.

in” or document neurological lesions. Development of the circuit-based view for brain functions such as emotions, memory
and behavior led to a more detailed examination of patients
with small cortical and subcortical lesions (Mega & Cummings,
1994). Symptom presentation became more understandable in
the context of small lesions localized within specific circuits. This
new understanding of the neuroanatomic bases for brain functions has been particularly applicable to psychiatric presentation
after traumatic brain injury (TBI), multiple sclerosis, ruptured
aneurysms, and cerebral vascular accidents. For the astute clinician, this knowledge can at times lead to prognostic information
for patients and treatment plan changes (Erhart, Young, Marder,
& Mintez, 2005; Diwadkar & Keshavan, 2002; Gupta, Elheis,
& Pansari, 2004; Symms, Jäger, Schmierer, & Yousry, 2004).
For example, a study of psychiatric patients without dementia
found that treatment was changed in 15% of patients after imaging exams (Erhart et al., 2005).
Clinical indicators for brain imaging include exposure to a
poison or toxin, dementia or cognitive decline of unknown etiology, delirium, brain injuries of any type with ongoing symptoms, new onset psychiatric symptoms after age 50, acute mental
status changes with abnormal neurological exam or autonomic
responses, new-onset atypical psychosis, and presence of symptoms that do not match with the “clinical norm” for the history.
In general, patients whose clinical symptoms do not fit the classic
historical picture for the working diagnosis should be considered
for some form of neuroimaging.

Cernak & Noble-Haeusslein, 2010; McAllister & Stein, 2010).
Traumatic brain injury (TBI) is a common occurrence in the
United States in both the civilian and military populations. An
estimated 1.7 million people receive urgent medical care for TBI
each year, and the true occurrence may be as high as 3.8 million
annually (Laker, 2011). Many of the estimated 2.4 million military personnel who have deployed to recent combat operations
have sustained at least one mild TBI (Rigg & Mooney, 2011; Epidemiology Program, 2012). Most individuals who experience a
mild TBI attain a complete recovery. Some will have residual cognitive and/or emotional symptoms sufficient to affect adjustment
to civilian life and family relationships. Multiple other conditions
may be present. Post traumatic stress disorder (PTSD), substance
misuse, depression, and chronic pain are commonly reported after return from service. Recent studies suggest possible long-term
adverse health effects, including the development of chronic traumatic encephalopathy (Chen, Kang, & Lin, 2011; McMillian,
Teasdale, Weir, & Stewart, 2011; Omalu et al., 2011; Goldstein et
al., 2012; McKee et al., 2012).
Both diffuse and focal injuries can occur in TBI (Taber, Warden, & Hurley, 2006; Andriessen, Jacobs, & Vos, 2010; McAllister
& Stein, 2010). The most common type of injury, particularly
in mild TBI, is to the fibers (axons) that form the connections
(white matter) within the brain. This is called diffuse axonal injury (DAI). The name is highly appropriate as this type of injury
usually affects only a small percentage of the fibers in an area and
frequently occurs in multiple locations within an individual brain
(Bigler & Maxwell, 2012; Shenton et al., 2012; Taber & Hurley,
2013). Areas of DAI are commonly too small for identification on
any of the standard clinical imaging techniques (Bigler & Maxwell, 2012; Shenton et al., 2012; Taber & Hurley, 2013). If large
enough for visualization (Figure 1), they will be much more likely
Figure 3

Added Value Example - SPECT Imaging

Clinical history: An adult male (early 30”s) was exposed to explosions multiple times (>30). Several events resulted in
alterations in consciousness (e.g., dazed, confused) and one event resulted in loss of consciousness ( ~ 1 hour). In the
year since that event he has experienced multiple new onset symptoms included problems with memory, headaches,
dizziness, word retrieval difficulties, photosensitivity, irritability, confusion, mood lability, increased anxiety, nightmares,
hypervigilance and insomnia.
Neuroimaging: Upper Row. At 1 year after the most recent event, multiple areas of DAI are clearly visible on clinical
MRI. Note that areas are better visualized on FLAIR than T2 weighted (T2W) MRI, and not well visualized on T1
weighted (T1W) MRI. Lower Row. Several areas were present in the white matter of one hemisphere in which the
fractional anisotropy (FA) was clearly lower than the same area of white matter in the other hemisphere. One of these
(circled) was used as a seed for tractography. Using a lesion as the starting point for tract reconstruction may provide
insight into the areas that have been disconnected by the lesion. (case and images courtesy of Dr. Shane McNamee,
Hunter Holmes McGuire VAMC, Richmond VA)

to be seen by MRI than CT. Gradient echo MRI is very sensitive
to the small areas of hemorrhage that sometimes occur in DAI.
Although clinical MRI is more sensitive than CT in detecting
DAI, even MRI is often negative, particularly in the chronic stage.
Functional imaging (cerebral blood flow, cerebral metabolic rate)
may be considerably more sensitive to the presence of TBI than
structural imaging (Figure 2). However, these techniques come
with their own challenges as they lack specificity.
Although still considered only research techniques at this
time, newer methods of MRI, such as DTI and DKI, are showing
promise for identifying small areas of white matter injury (Bigler
& Maxwell, 2012; Shenton et al., 2012; Hori et al., 2012). This is
important, because such injuries may have devastating functional
consequences. Multiple DTI studies have reported abnormalities
in specific metrics at various times after mild TBI, as recently reviewed in detail (Shenton et al., 2012). DTI provides metrics of
the speed and direction of water diffusion within each block (voxel) that makes up the image. Fractional anisotropy (FA), a measure
(scale of 0 to 1) of the average directionality of water diffusion, is
the most promising metric for identifying DAI. This is because
water diffuses much faster parallel to fibers than perpendicular to
fibers. White matter is rich in fibers and so has a high FA. FA is expected to be reduced in areas where fibers are disrupted. The most
common finding in mild TBI is multiple small areas of reduced
FA in white matter (Figure 3) (Shenton et al., 2012). However,
application of DTI to the study of mild TBI is still at an early stage
of development.
For DTI, or any other new brain imaging technique, to become clinically meaningful it must meet certain standards. Most
importantly, it must be able to reliably provide reproducible evaluations of an individual patient. This is very different from its use
in research studies, where groups of patients can be compared to
groups of healthy individuals. A much better understanding of
how much these measures vary within and across individuals is
needed in order to determine clinically meaningful change. There
are potentially multiple changes in the brain that, if reliably quantified, might be of value in diagnosis and clinical management of
mild TBI. These include the actual areas of injury as well as areas
undergoing changes as a result of metabolic, degenerative, adaptive, and/or compensatory processes.
References

Dr. Hurley received her Doctorate of Medicine from Medical University of
South Carolina in 1990 and completed her psychiatry residency with subspecialty focus on neuropsychiatry and neuroimaging research at Baylor College
of Medicine, Houston, Texas in 1994. Dr. Hurley remained at Baylor College of Medicine and the Houston VAMC as faculty in Psychiatry and Radiology until 2003. At that time, she transferred to the Salisbury, NC VAMC,
and joined the Wake Forest School of Medicine, where she is a Professor of
Psychiatry and Radiology. Dr. Hurley is a Diplomate of both the American
Board of Psychiatry and the United Council for Neurologic Subspecialties
Certification in Behavioral Neurology & Neuropsychiatry.
Dr. Taber received an MS in Neuroscience from the University of Florida in
1977 and a PhD in Neurophysiology from the University of Texas Houston
in 1982. She joined Baylor College of Medicine (Houston TX) in 1982 as a
Research Associate in the Departments of Neurology and Radiology, where
she conducted electrophysiological studies in rat hippocampal slices, magnetic resonance spectroscopy studies of intact brain in developing rat pups,
and participated in the founding of Baylor’s magnetic resonance imaging
and spectroscopy research center. From 1985 to 2003 she was faculty in
the Departments of Radiology and Psychiatry. During this time Dr. Taber
received the Fulbright & Jaworski Faculty Excellence Award for both her
teaching (2001) and for her enduring educational materials (2002). In 2003,
Dr. Taber pursued her long standing interest in medical informatics by joining the School of Health Information Sciences at the University of TexasHouston as a Research Fellow. In 2004 she collaborated with VA personnel
in North Carolina on a successful proposal for a VA-funded Mental Illness
Research, Education and Clinical Center (MIRECC). Dr. Taber has served
as the Assistant Director of Education for the VISN 6 MIRECC since 2005,
and as a Research Professor in the Division of Biomedical Sciences at the
Edward Via College of Osteopathic Medicine in Blacksburg, Virginia since
2007. She is also a Research Health Scientist at the Salisbury VA, where
her major focus is facilitating development of new researchers. Dr. Taber is
the author of more than 180 peer reviewed journal articles and more than
30 book chapters. She is co-editor of the “Graphic Anatomy” series for the
Journal of Computer Assisted Tomography and the “Windows to the Brain”
series for the Journal of Neuropsychiatry and Clinical Neurosciences. She
was elected a Fellow of the American Neuropsychiatric Association in 2005
and to ANPA’s Advisory Council in 2010. Her research interests include
traumatic brain injury, neuroimaging, medical informatics and education.

brain bytes
The Defense Department added new NFL Settlement
The NFL agreed to a $765 million settlement deal with more
than 4500 former players who sued the league, accusing it
of hiding the dangers of brain injury while profiting from the
sport’s violence, according to court papers. The NFL agreed
to fund medical exams, concussion-related compensation
and a program of medical research as well as to cover some
legal expenses. “This is a historic agreement, one that will
make sure that former NFL players who need and deserve
compensation will receive it, and that will promote safety for
players at all levels of football,” Judge Phillips said. “Rather
than litigate literally thousands of complex individual claims
over many years, the parties have reached an agreement
that, if approved, will provide relief and support where it is
needed at a time when it is most needed.”

study what happens to service members and veterans
who suffer mild traumatic brain injuries or concussions.
The principal investigator on the grant is David X. Cifu,
M.D., chair of the VCU School of Medicine’s Department of
Physical Medicine and Rehabilitation and executive director
of VCU’s Center of Researcher Sciences and Engineering
(CERSE). Groups of veterans who have been injured in
prior wars, such as Korea or Vietnam, in more recent wars
in Iraq and Afghanistan and in car accidents, sports and
falls in the United States will be studied. The researchers
will try to determine who is more likely to have problems
after these injuries, how the injured can be better treated
and cared for, and what the injured and their families can
expect over their lifetime.

The Concussed Brain at Work: fMRI Study Documents
Brain Activation During Concussion Recovery
SyNAPSe: A Randomized Double-Blind, PlaceboControlled Study to Investigate the Efficacy and Safety
of Progesterone in Patients with Severe Traumatic
Brain Injury
BHR is conducting SyNAPSe® (Study of the Neuroprotective
Activity of Progesterone in Severe Traumatic Brain Injuries),
a global, Phase 3, multi-center pivotal trial in severe TBI.
The study is evaluating the effectiveness of its proprietary
BHR-100 progesterone product as a neuroprotective agent
for the acute treatment of severe traumatic brain injury (TBI)
patients. Approximately 1,200 patients with severe (Glasgow
Coma Scale scores of 3-8), closed-head TBI will be enrolled
in the study at more than 150 medical centers in 21 countries.
Sites are located in the United States, Argentina, Europe,
Israel, and Asia.

VCU awarded $62 million to study traumatic brain
injuries in military personnel
Virginia Commonwealth University has been awarded a
$62 million federal grant to oversee a national research
consortium of universities, hospitals and clinics that will

For the first time, researchers
have documented irregular brain
activity within the first 24 hours
of a concussive injury, as well
as an increased level of brain
activity weeks later -- suggesting
that the brain may compensate
for the injury during the recovery
time. The findings are published
in the September issue of the
Journal of the International
Neuropsychological Society. The concussed athletes
showed the expected postconcussive symptoms, including
decreased reaction time and lowered cognitive abilities.
Imaging via fMRI (functional magnetic resonance imaging)
showed decreased activity in select regions of the right
hemisphere of the brain, which suggests the poor cognitive
performance of concussion patients is related to that
underactivation of attentional brain circuits. Seven weeks
post-injury, the concussed athletes showed improvement
of cognitive abilities and normal reaction time. However,
imaging at that time showed the post-concussed athletes
had more activation in the brain’s attentional circuits than
did the control athletes.
BRAIN INJURY PROFESSIONAL

27

Imaging for Brain Trauma:
Questions to Be Answered
By Jonathan M. Silver, MD

The rapid and exciting advances in brain imaging techniques
provide increasingly sensitive methods to examine brain structure and function. Compared to computed tomography (CT),
high powered 3 Tesla magnetic resonance imaging (MRI) provides anatomic detail that could only be visualized post-mortem. Diffusion tensor imaging (DTI) examines white matter
tracts in exquisite detail. The development of functional techniques, such as single photon emission computed tomography
(SPECT), positron emission tomography (PET), and functional MRI (fMRI), enable us to see that even normal appearing
brain does not always function normally, and different regions
may activate depending on the stimulus provided. Magnetic
resonance spectroscopy (MRS) analyzes chemical systems, volumetric analysis detects minute changes in brain volume, and
resting connectivity network analysis examines communication
among different networks. The promise of newer techniques,
such as shown in clarity where individual nerves and synapses
can be seen in preparations of brain tissue (although not in the
living animal) and the Blue Brain project (2013) the human
brain project (2013) show that even the current “high-power”
techniques reveal a fraction of what occurs in the brain.
While there is uniform excitement about the developments
in the detection of detailed neuroanatomical and physiologic
changes in patients who have sustained traumatic brain injury
(TBI), there is controversy about the clinical application of
this technology. It is interesting to observe that discussions on
28 BRAIN INJURY PROFESSIONAL

the role of imaging in the assessment of patients with TBI can
reach the emotional level of politics, global warming, or evolution. Psychiatrists are accustomed to treating patients with
disorders for which there are no “objective tests” to confirm
the biologic basis of their symptoms. We know that imaging in
other neurologic disorders do not always demonstrate pathology: for example, individuals with developmental disability, Parkinson disease, epilepsy, migraine headaches, early Alzheimer
disease, may have normal imaging on MRI or functional imaging. However, in none of these instances do we believe that the
disorders do not involve the brain. Similarly, when a disease
involves imaging abnormalities (such as white abnormalities in
migraine or multiple sclerosis), the extent of the abnormality
may not correlate with symptoms or disability. We also know
that careful imaging may help us in the clinical arean, such as
to determine if dementia is of the Alzheimer type vs. frontotemporal dementia. However, treatment usually is based on a
careful history, symptoms, and examination.
Unlike many other diseases, TBI occurs in unique and more
complicated situations, which involve an entirely new arena: different types of insurers (worker’s compensation, no-fault, disability) with their own process of evaluation, and the legal arena.
In addition, when “independent” evaluations are requested, we
must realize that payment can influence opinion, and set up a
“conflict of interest” that differs from the doctor-patient relationship. Instead of relying on history and symptoms, there is

the desire for an objective “gold-standard” confirmation that injury “really” occurred. This differs from the way tests are used in
medicine- and hence, the polarization of opinions.
Therefore, it is important, as a foundation, to not only understand what is involved in how these tests are performed,
but compare them to those we use frequently in medicine. For
patients with severe TBI, who have significant contusions or
bleeding, the routine imaging modalities demonstrate sufficient pathology to guide treatment (especially if we need to
determine there is a subdural hematoma that requires neurosurgical intervention). But in the injuries for which there is
brief or no loss of consciousness or transient amnesia, what is
the role for advanced imaging? Do we know if obtaining these
studies helps or complicates recovery?
Sensitivity and specificity

Many medical tests have been used for years, and we have information about the sensitivity (presence of the abnormality in
those who have the disease), and specificity (how likely are you
to have the disease if the test is abnormal). We need to know
how many in the general population will have the abnormality
and not have the disease, the natural history of the test (how
it changes with time in relationship to the disease), and if they
correlate with symptoms?
The electrocardiogram (ECG) is a routine test to detect
myocardial injury. The ECG may not detect many autopsyproven MI’s. ECG evidence of MI’s can disappear and return
to normal.(McQueen MJ 1983) Of non-fatal MI’s, half may
be “silent” (no clinical symptoms) and only discovered on subsequent ECG(Macfarlane 2007). Similar data is available for
large screening tests such as mammography or PSA,(Meigs,
Barry et al. 1996) where the “false positive” rate can be high
enough to question the utility of these as “screening tests.” It
is necessary to know the rate of abnormality of the test in the
general population to determine this. (For those interested, this
involves a very important concept known as Bayes Theorem).
In the 1980’s in psychiatry, there was excitement about
the use of neuroendocrine tests to diagnose depression (dexamethasone suppression test and thyrotropin hormone stimulation test). (Carroll, Feinberg et al. 1981; Extein, Pottash et al.
1982) However, enthusiasm waned when it was found that the
false positive rate in the general population made the test nonspecific for diagnosis.
Possibly most comparable to imaging for brain injury is
the literature on back pain. Studies have demonstrated that for
patients with low back pain, there is no relationship between
findings on MRI and recovery. In fact, more than twice as
many of those having MRI’s had lumbar spine operations than
those who received routine lumbar radiographs evaluations,
yet outcomes were similar. (Jarvik, Hollingworth et al. 2003)A
finding as “definite” as a lumbar disc bulge or protrusion (but
not extrusion) is found in over half of individuals without back
pain. (Jensen, Brant-Zawadzki et al. 1994)An MRI obtained
one year after surgery or conservative treatment for sciatica and
lumbar disc herniation in 283 patients did not distinguish between favorable and unfavorable outcome.(el Barzouhi, Vleggeert-Lankamp et al. 2013) Disk herniation was visible in 39%
with favorable outcome, and 33% with unfavorable outcome
(21% surgical group, 60% conservative treatment). A favorable

outcome was obtained in 85% with and 83% without disk herniation. Even in a disorder with much simpler pathology than
TBI, imaging has its problems.
Is more powerful imaging better?

A study that compared diffusion-weighted MRI in acute stroke
in 135 patients compared 1.5 vs. 3.0 Tesla magnets. The accuracy, sensitivity, and specificity was superior for 1.5T. Thus,
stronger may not be better. (Rosso C 2010)
Uniformity of analysis

Another issue with the newer technologies is whether there is
a uniformly accepted methodology of analysis. There are several possible ways to analyze an imaging study: Whole brain
vs. region of interest; Statistical group analysis; individual
scans or types of lesions (Jorge RE 2013; Kim N 2013), visual vs. computer (volumetric analysis) (Zhou, Kierans et al.
2013). When there is a lesion, do we know the natural history
of the abnormality, whether it is static or dynamic.(Lipton ML
2012) We want to avoid calling a lesion permanent if it changes
with time. This has especially been true for the “functional”
(SPECT, PET) imaging that can change based on mood, pain,
anxiety, and the conditions of the room.
Co-occurring disorders

Does the co-occurrence of other disorders influence abnormalities? Many individuals have had a prior concussion (which is
fairly common)- so we are unable to determine when the abnormality may have occurred. Abnormalities may be seen with
a variety of neuropsychiatric conditions, such as anxiety, depression, pain, and migraine headaches.
Implications for abnormal imaging

What are the implications for an abnormal imaging study? At
this time, there is no treatment based on an abnormal image.
We know that expectation of prognosis influences prognosis for
a number of diseases, including concussion.(Hou, Moss-Morris
et al. 2011; Snell, Siegert et al. 2011) Would an abnormal brain
imaging study make the person feel more or less optimistic about
recovery? Does this depend on the chronicity of the symptoms.
For example, would a patient react differently if an abnormal
study was obtained 3 months vs. 3 years after continuing symptoms? In reality, we do not know, and no one has ever asked this
question.
How does an abnormal result correlate with prognosis? How
many asymptomatic patients have been studied with a specific
modality to see how the result correlates with symptoms (similar to the herniated disc studies)? Many patients with migraines
and multiple sclerosis are functioning well despite the presence
of significant white matter pathology.
While an abnormal imaging study may significantly help a
lawyer to demonstrate that a brain injury occurred, clinicians
must be aware of the promises as well as potential limitations
and adverse consequences of these tests. Neuroimaging of brain
injury is a rapidly developing and important modality in our
understanding of the changes that occur during all severities of
TBI. We must not let our enthusiasm override the critical questions that need to be asked (and answered) so that we are able to
use these techniques to help our patients.
BRAIN INJURY PROFESSIONAL

Jonathan M. Silver, M.D. is Clinical Professor of Psychiatry at New York
University School of Medicine. Dr. Silver is a Fellow and past- President of the American Neuropsychiatric Association. He is a Diplomate
in Behavioral Neurology & Neuropsychiatry by the United Council for
Neurologic Subspecialties (UCNS), and is Chair of their committee that
developed the first certification examination. He is Associate Editor of
the Journal of Neuropsychiatry and Clinical Neurosciences and Journal
Watch Psychiatry, and Psychiatry Section Editor for UpToDate. He has
held past positions as Director of Neuropsychiatry at Columbia-Presbyterian Medical Center, and Assistant Chair of Clinical Services and
Research and Director of Ambulatory Services in the Department of Psychiatry at Lenox Hill Hospital in New York City. He has authored over
45 papers and 55 chapters, focusing on the neuropsychiatric problems
subsequent to traumatic brain injury and the pharmacologic treatment
of those problems. He has lectured widely throughout the United States
and Canada on these topics, and has made over 160 presentations at
scientific meetings. He is senior editor of the books “Neuropsychiatry
of Traumatic Brain Injury,” and “Textbook of Traumatic Brain Injury”,
which has just published the second edition. He has been listed in “Best
Doctors in America” since 1992 for the area of neuropsychiatry. He received the award for “Innovative Clinical Treatment” from the North
American Brain Injury Society.

brain bytes
Traumatic Brain Injury Treatment for
Service members
Service members who have suffered
severe traumatic brain injuries and
psychological ills can benefit from an
intensive four-week program at the
National Intrepid Center of Excellence.
Dr. James Kelly, Director of the National
Intrepid Center of Excellence, states that
“When service members with severe TBI
fail to respond to conventional medical
treatment, they often are referred to
NICoE’s program, which finds the best
methods to treat their conditions on an
individual basis. The patients must also
have a co-existing psychological health
issue, such as post-traumatic stress
disorder, depression or anxiety.”
The only center of its kind, the Defense
Department’s NICoE “…offers a wealth
of medical and alternative approaches
for such service members, with medical

professionals such as neurologists,
therapists and counselors working in
an interdisciplinary team approach”,
Dr. Kelly explained. “Whatever patients
need, they get,” the Director said,
adding that “NICoE does not operate
in an assembly-line format, but rather
as a compact, intensive care outpatient
program that treats different patients with
individualized forms of care that fit their
particular needs.”
Reported by Terri Moon Cronk,
American Forces Press Service
Project Brain announced by President
Obama
President Obama announced that his
budget for 2014 will include $100 million
for the project called BRAIN: Brain
Research through Advancing Innovative
Neurotechnologies (BRAIN). Already the

initiative is being compared to the Human
Genome Project, which finished decoding
the genetic pattern that makes all humans
unique in 2003.
While the brain mapping project has
also been compared to President John
F. Kennedy’s 1961 challenge to land a
human on the moon, brain researcher
Professor Eric Kandel says this will be
harder. “Going to the moon – I don’t mean
to in any way minimize it – was in part an
engineering project. This brain research
is going into the unknown. This is like
Columbus discovering America, if you
will,” Dr. Kandel, who won the Nobel Prize
in 2000 for his research on the brain.
Neuroscientists hope Project BRAIN
will allow them to map the connections
between individual neurons and large
circuits of neurons to unlock the secrets
behind Alzheimer’s, Autism, strokes,
traumatic brain injuries (TBIs), and some
psychiatric disorders.

Rebuilding Lives After Brain Injury
NeuroRestorative is a leading provider of post-acute rehabilitation and support services for
adults and children with brain injuries and other neurological challenges.
Our continuum of care and community-based programs include:
n

n

n

n

Neurorehabilitation
Neurobehavioral
Supported Living
Transitional Living

n

n

n

n

Host Home/In-Home
Day Treatment
Outpatient
Respite

NeuroRestorative has programs across the country. Visit our
website for information on specific program locations.

800–743–6802 referral line

NeuroRestorative.com
BRAIN INJURY PROFESSIONAL

31

legal spotlight
Hope2
It has often been said that Hope is not a plan, but maybe it
shoul\d be.
As one of the pastors at our local church I often encounter
people who have lost hope are just about ready to give up and
surrender to their circumstances. In those moments I have a
choice. I can pat them on the back and say “I’ll pray for you” and
be on my way or I can impart something eminently more useful.
I can give them Hope.
Regrettably, Hope is not something that we were taught in
our legal or medical school education as a means by which we
could in many cases care for our clients and patients. But maybe it should have been. As a TBI lawyer having represented
clients from the homeless to CEO’s I have discovered a fundamental human need: people need Hope. I recall a few years
ago meeting with Jim, the CEO of a healthcare company many
of whose patients were in the acute phase of TBI. Jim came to
see me because his 19 year old son had just been in a terrible
car accident leaving him in a coma. When I first saw Jim who
was usually a very well dressed, confident looking executive,
he looked uncharacteristically tired, disheveled, and worried.
Although Jim was a person of influence and understood well
the complexities of a TBI, he was on that day as he described
it, “in a fog”.
After listening to him and explaining how our law firm could
help, I sensed he needed something more than a legal analysis
and an explanation of our in-house care management services.
I could see in his eyes that what he really needed was Hope.
I didn’t have the courage or confidence to tell him that his son
was going to be ok. But I did listen and encouraged him to
believe that through the long road to recovery, his son would
get better. I am relieved to report that he did. Today, Jim’s son
is in graduate school and doing well. Since then, every time I
see Jim I can perceive his gratitude for our conversation that
day. I believe my impact on Jim’s life had less to do with the
settlement we obtained and more to do with taking the time to
compassionately connect with him. Lesson learned.
It is similarly impactful to be the recipient of Hope. Two
months ago my older brother, Jorge suffered a stroke. That he
survived is nothing short of miraculous. He was left with right
sided hemiparesis. Jorge has received excellent and compassionate medical and rehabilitative care. But the best care he received, in my opinion, came recently. He was seen by a prominent South Florida neurologist whose normal waiting room time
is several hours. He waited. It was worth the wait.
During the 30 minutes, my brother went from anxiety and
discouragement about his condition and future prospects, to
being motivated and encouraged. So what happened? My
brother wouldn’t share with me precisely what the neurologist

32 BRAIN INJURY PROFESSIONAL

told him but I got the gist of what happened. This neurologist
went beyond his training and intuitively sensed that my brother
needed more than a physical exam, diagnosis and a prescription for OT, PT and Speech.
He accurately perceived that he needed Hope and he gave
it to him. I have not seen my brother this motivated to do anything, ever. He is committed to regaining his life.
Whatever inspiration that neurologist gave Jorge; it’s working, because he is well on his way to an excellent recovery.
These two experiences I have shared with you underscore an
important lesson for all of us as we represent and care for families living with TBI. The lesson is this: there is great power in
an encouraging word given at the appropriate time. But all too
often we can be dismissive of hope since it is not quantifiable or
we assume that it will only lead to patient/client disappointment
and unfulfilled expectations.
As medical and legal professionals we are uniquely positioned to positively influence our patient/clients perspective on
their brain injury.
Our opportunity to help transform lives can help move the
families we serve from being brain injury survivors to brain injury triumphants.

About the Author

Frank Toral is the Senior Partner of Toral Garcia Battista, a
Florida-based law firm focusing on brain and spinal cord injury cases. Frank is a passionate
advocate for brain and spinal cord
injury survivors and their families
and has served in various leadership and advisory roles with multiple
organizations including Brain Injury
Association of Florida, Brain Injury
Association of America, Sarah Jane
Brain Foundation and the University
of Florida Presidents Council. Frank
received his Bachelor of Science in
Political Science from the University
of Florida and his Juris Doctorate from Shepard Broad Law
School at Nova Southeastern University. Frank is a frequent
speaker and contributor on Brain injury topics and issues and
has also authored the handbook Brain Injury: Where do we go
from here?. Frank founded the Toral Family Foundation whose
mission is to collaborate with the healthcare community to improve the lives of all persons with a brain or spinal cord injury
through research, education and access to resources.

Acute
Hospitalization
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Visit our website for more information, to arrange a facility tour, or to make a referral.

BRAIN INJURY PROFESSIONAL

33

bip expert interview
Interview with Jamshid Ghajar, MD, PhD

Jamshid Ghajar completed the MD/PhD program at Cornell University Medical College, with
a PhD dissertation in neurochemistry and brain metabolism during coma. After completing his
residency training in neurosurgery at the New York Presbyterian Hospital, he joined the Cornell
faculty and founded the Brain
Trauma Foundation (BTF), where he currently serves as President. Dr. Ghajar is Chief of Neurosurgery at Jamaica Hospital-Cornell Trauma Center, Clinical Professor of Neurological Surgery
at Weill Cornell Medical College and President of BTF. He resides in New York City with his wife
and three daughters.

What is the Brain Trauma Foundation’s
mission?
BTF’s mission is to translate neuroscience
into effective solutions. BTF’s evidence-based
severe TBI Guidelines have led to a 50% reduction in head injury deaths in the U.S. and
are the standard of traumatic brain injury care
worldwide.
BTF currently has a contract with the U.S. Department of Defense (DOD) to develop an eye
tracking device that can assess cognitive performance and concussion within 30 seconds.
This device is being field tested in 10,000 soldiers and athletes. BTF is also funded by the
DOD on evidence based concussion guidelines, in collaboration with the CDC.
What is “Eye-tracking” and what does it
measure?
At BTF, when we say “Eye-Tracking” we are
most frequently referring to two specific types
of eye-movement: Saccadic (quick, repositioning of the eyes) and SPEM (Smooth Pursuit
EyeMovement; ontinuous stabilization of a visual image of a moving target). Humans use
a combination of saccadic and smooth pursuit
eye movements to select visual information for
processing, or in lay terms, to “pay attention.”
Numerous previous studies have demonstrated that SPEM is highly dependent on attention
and attentional and oculomotor processes are
tightly integrated at the neuronal level. Functional magnetic resonance imaging (fMRI) research has demonstrated that SPEM control
relies on a neural network comprising the motion perception area V5, the posterior parietal
34 BRAIN INJURY PROFESSIONAL

cortex (PPC), the frontal eye field (FEF), the
supplementary eye field (SEF), the dorsolateral prefrontal cortex (DLPFC), and the cerebellum. These areas are also activated in other
attention dependent tasks.
SPEM is a particularly sensitive measure of
attention as it requires an individual to predict
and maintain target velocity and trajectory,
employing spatial working memory and visual
feedback to continuously adjust eye gaze position for accuracy when following a target.
Using a target moving in a predictable circular path, predictive timing can be accurately
measured.
BTF working closely with its neuro-technology
partner SyncThink (www.syncthink.com) developed a specific test of SPEM, called EYESYNC. This test measures eye tracking performance within 30 seconds, has high test retest
reliability and little effort or learning effect,
which are inherent problems in neurocognitive
testing.
What are the current applications for the
EYE-SYNC test?
Currently, the military is interested in using
EYE-SYNC to assess a soldier’s readiness for
duty, such as understanding potential impairment from fatigue or concussion. Athletic organizations also recognize the importance of first
accurately describing and then appropriately
triaging a concussed athlete. EYE-SYNC is one
metric that can help characterize changes in attention functioning that may have an impact on
an athlete’s return to play, or a soldier’s return
to duty.

What is the goal of your current Concussion
work?
We are using an evidence-based method (that
is, a systematic, transparent process using only
data from high quality published literature) to
derive clinically useful instruments for immediate identification, diagnosis, and prognosis of
concussion.
Screening and diagnostic criteria already exist. Why are you creating another version?
From our review of the existing methods for diagnosing concussion, we found that all - either
entirely or at least in part - rely on expert opinion or group consensus. The evidence-based
method relies solely on solid data. As such we
believe the instruments that method will render
will be more reliable and valid. Our hope is that,
after sufficient validation, the instruments will
become standard across settings, and will minimize the vast amount of variation we see in both
diagnosis and treatment of concussion.
You have used the evidence-based method to develop guidelines for severe brain
trauma. What do you think has been accomplished by this work?
We recently conducted an analysis that is in
press, culminating data from a 10-year project
to implement the Guidelines in New York State
trauma centers. The results show there was
a 50% reduction in mortality associated with
adherence to the Guidelines. The magnitude
of that improvement far exceeds what is generally seen in research about clinical interventions for any disease, and far exceeds any
expectations from TBI clinical or basic science
research.

literature review
Textbook of Traumatic Brain Injury, 2nd Edition.
By Jonathan M. Silver, MD
Thomas W. McAllister, MD
Stuart C. Yudofsky, MD
American Psychiatric Publishing, Inc. Washington, D.C., 2011.
While some might say the review of a 2011 Textbook on Traumatic Brain Injury is a bit delayed, that’s accurate, yet the contribution of this text to the field of brain injury should not go
un-recognized in the Brain Injury Professional albeit late.
Many years ago, as a young behavioral psychologist, a client taught
me a powerful lesson in differential
diagnosis. Severe orientation and
memory impairments mimicked psychosis when this gentleman presented with what appeared to be visual
hallucinatons of gremlins prompted
by a horror movie the evening before, an inability to accurately connect the dots from real events, and
an overwhelming sense of fear. Not long after, another client who mistook his rehabilitation facility for a submarine, attempted to order drinks from a floor plant, had a history of 4
point restraint with a 24 hr. guard, experienced middle of the
night “awakenings” and lucid moments. His major depression
and subsequent course of pharmacotherapy and behavioral
therapy might have taken a different route had we mistaken
his cognitive difficulties for psychosis. We all have our stories of successes or near misses in which we could have gone
down a misguided treatment path and in some cases we may
not have known we missed a crucial piece of the neuropsychiatric equation.
Dr’s Silver, McAllister, and Yudofsky have been literally writing the book on neuropsychiatry and brain injury for the past
two decades. They teach us to look beyond the more obvious
explanations to help determine the underlying neuropsychiatric issues that may often be misdiagnosed, misunderstood, or
underrepresented. This oversight can result in inadequate or
ineffective treatment or delayed treatment which may result
in more challenging or resilient future unwanted behaviors or
symptomotology.
Changes in personality and behavioral issues are often
cited as having the most enduring impact 1, 5, and 15 years fol-

lowing brain injury. This 2nd edition text includes 39 chapters
in 5 sections, Epidemiology and Pathophysiology, Neuropsychiatric Disorders, Neuropsychiatric Symptomatologies, Special Populations and Issues, and Treatment. It includes contemporary issues in sports injuries, brain injury in the context
of war, PTSD, substance issues, and pediatric brain injury and
abuse. It reflects evidence based or best available evidence
approaches and offers a chapter on emerging complementary
treatment approaches. The authors outline a comprehensive
neurorehabilitation approach that includes neuroradiological,
neuropsychological, and neuropsychiatric assessment including possible genetic testing and combined psychopharmacological, cognitive therapy, psychotherapy, and positive behavioral approaches to treatment.
The book is intended as a reference for practitioners by ensuring each chapter can stand alone with a format that includes
Key Clinical Points and Recommended Readings and References following each chapter. The authors also chose a powerful foreword by Bob and Lee Woodruff who know firsthand the
life-altering impact of a brain injury and who like many families,
derive hope from new research and treatments. I do however,
think in future editions the title “Textbook of Neuropsychiatry in
Traumatic Brain Injury” might better reflect the contents while
continuing to outline a broad perspective on contributing issues
and in assessing and treating neuropsychiatric issues in persons
with brain injury throughout their developmental life-span.

About the reviewer

Dr. Debra Braunling-McMorrow is
the President and CEO of Learning
Services. She serves on the board
of the North American Brain Injury
Society. Dr. McMorrow is a past chair
of the American Academy for the
Certification of Brain Injury Specialists (AACBIS) and has served on the
Brain Injury Association of America’s
board of executive directors. Additionally, Dr. McMorrow has served on
several national committees, editorial
boards, and peer review panels. Dr. McMorrow has published in
numerous journals and books and has presented extensively in
the field of brain injury rehabilitation. She has been working for
persons with brain injuries for almost 30 years.

BRAIN INJURY PROFESSIONAL

35

non-profit news
NORTH AMERICAN BRAIN INJURY SOCIETY
Close to 400 brain injury professionals gathered at the InterContinental Hotel in New Orleans to attend the North
American Brain Injury Society’s 11th Annual Conference on
Brain Injury and the concurrent event, the 26th Annual Conference on Legal Issues in Brain Injury. The meeting opened
with a special pre-conference workshop on state of the art
neuroimaging chaired by John Silver, MD, Barry Willer, PhD
and John Leddy, MD. The plenary session during the first
day of the meeting featured talks by Jonathan Silver, Keith
Cicerone, Gary Ulicny, Matthew Dodson, Barry Willer, Jeffrey Kreutzer, Tom Gennarelli and Asghar Rezaei. The following two days featured 35 invited speakers and 38 oral
presentations from peer reviewed submissions. NABIS was
honored to present achievement awards to Geoff Lauer (Public Policy), Jeffrey Kreutzer (Innovative Treatment) and Keith
Cicerone (Research).
It is not too early to mark your calendars for the 2015
NABIS meeting! In support of the International Brain Injury Association’s Tenth World Congress on Brain Injury,
NABIS will not be holding its regular conferences next year,
and all NABIS members are encouraged to attend the World
Congress to be held March 18-21, 2014, in San Francisco.
NABIS will be back with our regular meetings April 29 – May
2, 2015, at the beautiful Westin Riverwalk Hotel in San Antonio, Texas! Details as they become available will be posted
on the NABIS website, www.nabis.org.

Brain Injury association of america
The Brain Injury Association of America (BIAA) has announced that Donald G. Stein, Ph.D. has been named as the
recipient of the 2013 William Fields Caveness Award, and that
Brent E. Masel, M.D. will receive the Sheldon Berrol M.D.
Clinical Service Award. Awards will be presented at ACRM’s
fall meeting in Orlando, FL in November. BIAA is actively
lobbying for reauthorization of the TBI Act (H.R. 1098) to
continue and expand protection and advocacy grant programs
as well as the critical work of the Centers for Disease Control
and Prevention. Please contact your congressional representative and ask him/her to co-sponsor the bill. Sens. Mark Kirk
(R-IL) and Tim Johnson (D-SD) introduced S. 1027 on May
22, 2013 to improve, coordinate, and enhance rehabilitation

36 BRAIN INJURY PROFESSIONAL

research at the National Institutes of Health (NIH). The bipartisan legislation would implement some of the recommendations raised in the Final Report of the Blue Ribbon Panel
on Medical Rehabilitation Research at NIH. BIAA will present the 2014 Brain Injury Business Practice College at the
Green Valley Ranch Resort and Spa in Las Vegas, NV, Jan.
21-23, 2014. Sessions offered can enable business executives
and managers to improve their business methods and metrics.
For more information, visit: www.biausa.org/businesspracticecollege.

DEFENSE CENTERS OF EXCELLENCE
This quarter’s update from DCoE highlights the new website
T2WRL, pronounced “twirl.”
T2WRL is a resource locator for Defense Department
and Veterans Affairs traumatic brain injury (TBI) case managers and care coordinators supporting the discharge planning and ongoing care for service members, veterans and
their families coping with TBI and associated psychological
health concerns.
TBI has been described as the signature wound of the Afghanistan and Iraq conflicts. Modern body armor has greatly
enhanced a warrior’s chance of survival after sustaining a TBI;
however, with increased awareness and screening measures,
mild TBI (also known as concussion) has become a clinical
challenge for those charged with caring for chronic symptomatic mild TBI patients.
Ms. Katherine Helmick, Deputy Director for the Defense
Veterans Brain Injury Center (DVBIC), stated, “This new
resource gives case managers and care coordinators centralized access to military, Veterans Affairs and community TBI
resources and information including 200 websites and 1,200
facilities with updates being added regularly. T2WRL is a tremendous asset for those caring for our military members and
veterans suffering from TBI.”
Additional features of the T2WRL website include:
•

•
•

Over 40 search topics are listed and include advocacy, behavioral health, community reintegration, emergency services, occupational therapy, sleep disorder treatment, social
services and vocational training and work therapy
Searches can be filtered by treatment areas, organization or
service type
Results are displayed by geographic proximity using inter-

•

active maps
Users may suggest new resources and updates to existing
resources

To create a profile to access the locator, visit ttwrl.dcoe.mil. For
information about DCoE, please visit dcoe.health.mil or email
the DCoE Outreach Center at resources@dcoeoutreach.org or
phone 866-966-1020 (staffed 24/7).

INTERNATIONAL BRAIN INJURY ASSOCIATION
The official Call for Abstracts for the Tenth World Congress
on Brain Injury submission deadline is October 11, 2013.
Members of NABIS and all multidisciplinary brain injury professionals are encouraged to submit their original research to
what is expected to be one of the most important brain injury
events ever held in the United States. The event is scheduled
for March 19-23, 2014, in San Francisco, California. The
Congress scientific committee will determine the most appropriate format for the presentation, either oral platform or poster. In addition to the oral and poster sessions, the Congress will
feature a host of world renowned invited speakers, panels and
workshops providing attendees with state-of-the-art research
on brain injury research, assessment and treatment. Members
of NABIS should note that they are entitled to register for the
Congress at the discounted IBIA member rate. For more information, visit www.internationalbrain.org.

NATIONAL ASSOCIATION OF STATE HEAD INJURY
ADMINISTRATORS
The National Association of State Head Injury Administrators
24nd Annual State of the States (SOS) in Head Injury Meeting “From Model T’s to Modern Times: Emerging Trends in Brain
Injury” will be held October 7-10, 2013, in Detroit, Michigan at
the Dearborn Inn. The SOS Meeting is the only annual national
gathering which provides professional development opportunities among state government program administrators specifically
in the field of traumatic brain injury. The Meeting will feature
keynote speakers presenting on issues impacting brain injury and
state services, national trends, and federal policy.
The pre-conference, “Brain Injury, Violence and At-Risk
Populations” will focus on shedding light on the connections
of pediatric, adult and older adult violence and brain injury

and learning how states can foster connections within these
areas of focus.
Save the Date: 2014 SOS Conference October 27 - 30,
2014 in Philadelphia, PA!
NASHIA, its partners, and the Congressional TBI Taskforce continue their efforts on the re-authorization of the TBI
Act which includes:
•

•
•

The Health Resources and Services Administration
(HRSA) to provide funds to states to develop TBI programs that improve access to service delivery for individuals with TBI.
Funding to Protection and Advocacy services in each state
to ensure legal services are available for individuals with
TBI.
Funding to Centers for Disease Control and Prevention
(CDC) for surveillance, outreach, and prevention efforts
specific to TBI, including the creation and dissemination
of treatment guidelines.

Remember to contact your legislators to support this vital
piece of legislation! Information on SOS, state TBI programs,
NASHIA technical assistance, and other resources may be
found at www.nashia.org.

UNITED STATES BRAIN INJURY ALLIANCE
One year ago, a handful of leading brain injury groups joined forces to create the United States Brain Injury Alliance (USBIA). Today, the success of the initiative can be measured by the joining of
20 state groups as USBIA members. More importantly, though,
it is a testament to the groups’ collective commitment to working
towards enhancing the quality of life for people affected by brain
injury. To see the list of member states, visit www.usbia.org.
While we reflect on the attainment of USBIA and the growing strength of the brain injury awareness movement, we remain
committed to our mission. On July 29, 2013, USBIA Board
Chair Barbara Geiger-Parker attended a meeting with U.S. Department of Health and Human Services Secretary Kathleen Sebilius and several of her advisors. Organized by the Sarah Jane
Brain Foundation, Barbara was part of a delegation of 10 people
from around the nation, including former Congressman Patrick
Kennedy, representing those affected directly by brain injury,
professionals and advocates to discuss issues of importance regarding pediatric brain injury.

BRAIN INJURY PROFESSIONAL

37

legislative roundup
“It’s the same old story but it’s told a different way. The more things change
the more they stay the same - the same sunrise, it’s just another day.”
— Bon Jovi
When Congress returns in September, members will be faced with
spending bills to continue federal programs beginning October 1st,
the new fiscal year, while at the same time needing to address the
debt ceiling in order to pay bills already authorized in prior spending bills. In the middle of this debate is the implementation of
“ObamaCare”, the Affordable Care Act (ACA), which authorized
federal and state health insurance exchanges to be open on October
1st to help people to compare and purchase health insurance. The
House of Representatives, however, continues to pass legislation repealing the healthcare reform law, having passed repeal legislation
40 times.
As in the past four years, Congress is likely to extend federal
spending beyond September 30th through a short-term continuing
resolution (CR). Both the House and the Senate Appropriations
Committees are far apart with regard to spending for domestic discretionary programs, including the continuation of the across-theboard cuts enacted in the spring due to sequestration. The House
appropriation bills would limit total FY 2014 funding to the sequester level plus additional cuts to domestic programs in order to
restore defense spending.
In July, the Senate Appropriations Committee approved the Labor-HHS-Education FY 2014 spending bill, which funds prevention, research, education, and disability and health care programs.
The recommendations include funding increases for CDC’s Injury
Center to reduce gun violence through research and to expand the
National Violent Death Reporting System beyond the current 18
states which participate in the reporting system. The Senate Committee also proposed using $3 million through the Prevention and
Public Health Fund (PPHF) to expand older adult falls prevention activities in coordination with the U.S. Department of Health
and Human Services’ (HHS) Administration for Community Living (ACL), which was provided an increase of $7 million through
PPHF for complimentary activities. The Committee also included
report language to encourage CDC to collaborate with academic centers and sports-affiliated organizations to test and improve
sports safety equipment to reduce traumatic brain injury (TBI)/
concussions.
The Senate Committee on Health, Education, Labor, and Pensions (HELP) has marked up S.1356, the Workforce Investment
Act of 2013, which reauthorizes the job training programs authorized under the Workforce Investment Act of 1998 and programs
authorized by the Rehabilitation Act of 1973, as amended. The legislation makes a number of substantial changes with regard to the
administration of the vocational rehabilitation (VR) programs. The
bill renames the Rehabilitation Services Administration (RSA) to
the “Disability Employment Services and Supports Administration”
and transfers RSA from the U.S Department of Education (DOE)
to the U. S. Department of Labor (DOL); moves the Independent
Living Program from DOE to the HHS’ ACL; moves the National
Institute on Disability and Rehabilitation Research (NIDRR) to
the ACL; and changes the name of NIDRR to the “National Institute on Disability, Independent Living and Rehabilitation.”
38 BRAIN INJURY PROFESSIONAL

During the summer, the Commission on Long-Term Care,
created by the American Taxpayer Relief Act of 2012, convened
meetings in keeping with its charge to develop a plan for a comprehensive, coordinated, and high-quality system that ensures the
availability of long-term services and supports for individuals who
are elderly, or with substantial cognitive or functional limitations,
or who require assistance to perform activities of daily living, as well
as individuals desiring to plan for future long-term care needs. You
can follow the Commission’s work on its website: www.ltccommission.senate.gov.
While Congress addresses federal spending and other issues, the
Administration continues to push forward on the implementation
of health care reform. To assist individuals seeking information on
health insurance through the health exchanges, HHS has awarded
Navigator grant applicants in Federally-facilitated and State Partnership Marketplaces. HHS has launched a new website for consumers, HealthCare.gov, and a 24-hours-a-day consumer call center ready to answer questions in 150 languages. More than 1,200
community health centers across the country are preparing to help
enroll Americans who are uninsured.
At the same time, the Administration is also proposing changes
which would reduce spending for post-acute care under the Medicare program. These proposed changes include bundled payments,
beginning in 2018, for post-acute care providers, including longterm care hospitals, inpatient rehabilitation facilities, skilled nursing facilities, and home health providers. Members of Congress are
also reviewing the President’s budget proposals and the impact on
individuals with disabilities and health care providers.
Meanwhile, in accordance with the TBI Act 2008 amendments,
CDC has released its report to Congress, Traumatic Brain Injury
in the United States: Understanding the Public Health Problem
among Current and Former Military Personnel. The report presents the major findings and recommendations of the members of
the CDC, NIH, Department of Defense (DoD), and Department
of Veterans Affairs (VA) Leadership Panel, who were charged with
determining how best to improve the collection and dissemination
of information on the incidence and the prevalence of TBI among
persons who sustained these injuries while in the military. It is available on the CDC website: www.cdc.gov/traumaticbraininjury/
pubs/congress_military.html.
About the Editor

Susan L. Vaughn, S.L. Vaughn & Assoc., is the
Director of Public Policy for the National Association of State Head Injury Administrators
and consults with the Brain Injury Association of
America on state policy issues. She retired from
the State of Missouri in 2002, after working nearly 30 years in the field of disabilities and public
policy. She served as the first director of the Missouri Head Injury Advisory Council, a position
she held for17 years. She founded NASHIA in
1990, and served as its first president.

Legal Representation Care Management
Brain Injury Attorneys
“In every serious injury case we have the opportunity to
help make a difference in the recovery and the quality of
life of our clients and their families that goes far beyond
the legal scope.”
-Frank Toral, Esq., Senior Partner

Improving Lives through Caring, Commitment and Community
Toral Garcia Battista Attorneys at Law firmly
believe that the responsibility of a law practice is
not simply a successful settlement but rather
providing an individual who has suffered a lifealtering injury, the resources needed to lead a
greater quality of life. Focusing on Traumatic Brain
Injuries and Spinal Cord Injuries, the TGB firm
structure supports care management in the
medical and social elements of the clients’
situation through the employment of a team that
includes a Registered Nurse and Licensed Clinical
Social Worker.
The legal and care management team works collaboratively to address the
comprehensive needs of the client and facilitate navigating the complex
system of care.

The Toral Family Foundation, a 501(c)3 nonprofit organization based in Ft. Lauderdale Florida, is committed
to collaborating with the healthcare community to improve the lives of all persons with a brain or spinal
cord injury through research, education and access to resources.
www.toralfamilyfoundation.org